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N371 Abbreviations
Medical Documentation Abbreviations
| Question | Answer |
|---|---|
| a | before |
| Aa | of each |
| AAO x3 | Awake, alert, oriented to place, person and time |
| Abd | abdomen, abdominal |
| ABG | arterial blood gases |
| Abn | abnormal |
| a.c. | before meals |
| ADA | American Diabetic Association, American Medical Association |
| ADL | activities of daily living |
| ad lib | as directed |
| AFB | acid fast bacillus |
| AKA | above knee amputation |
| a.m. | before noon (morning) |
| AMA | against medical advice |
| amt. | amount |
| ASA | aspirin |
| ASCVD | arteriosclerotic cardiovascular disease |
| ASHD | arteriosclerotic heart disease |
| Ax | axillary |
| B, bil. | bilateral |
| B/A | backache |
| BBS | bilateral breath sounds |
| B.E. | barium enema |
| Bid, BID | twice a day |
| BK | below knee |
| BKA | below knee amputation |
| BM | bowel movement |
| BP, B/P | blood pressure |
| BPH | benign prostatic hypertrophy |
| BR | bedrest |
| BRP | bathroom privileges |
| BS | breath sounds |
| BS | bedside |
| BSC | bedside commode |
| BUN | blood urea nitrogen |
| BX, bx. | biopsy |
| c | with |
| CA | cancer, carcinoma |
| CAD | coronary artery disease |
| Caps | capsules |
| Cath | catheter, catherization |
| CBB | complete bedbath |
| CBC | complete blood count |
| CBR | complete bedrest |
| CBS | chronic brain syndrome |
| CC, cc | chief complaint |
| CDI | clean, dry, intact |
| CHF | congestive heart failure |
| circ. ck. | circulation check |
| cm. | centimeter |
| CNS. | central nervous system |
| c/o | complains of |
| CO2 | carbon dioxide |
| cont'd | continued |
| COPD | chronic obstructive pulmonary disease |
| CPT | chest physiotherapy |
| Cr. | creatinine level |
| CRD | chronic respiratory disease |
| CSF | cerebrospinal fluid |
| CT | computerized tomography |
| CVA | cerebral vascular accident |
| CXR | chest x-ray |
| D & C | dilation & curettage |
| Diab. | diabetes, diabetic |
| DOA | dead on arrival |
| DOB | date of birth |
| DOE | dyspnea on exertion |
| DM | diabetes mellitus |
| DTR | deep tendon reflexes |
| DT's | delirium tremens |
| Dx | diagnosis |
| EBL | estimated blood loss |
| ECHO | echocardiogram |
| ED | emergency department |
| EEG | electroencephalogram |
| e.g. | for example |
| EKG, ECG | electrocardiograph |
| Elix. | elixir |
| ENT | ear, nose, throat |
| EOM | extraocular movement |
| ER | emergency room |
| etiol. | etiology |
| ETOH | alcohol |
| exp. lap | exploratory laparotomy |
| F. | fahrenheit |
| FBS | fasting blood sugar |
| fl. | fluid |
| fly. | family |
| FOB | foot of bed |
| FPP | fall prevention program |
| Fr., fr. | french |
| freq. | frequency, frequently |
| FUO | fever of undetermined origin |
| fx. | fracture |
| g, GM | gram |
| GB | gallbladder |
| GFR | glomerular filtration rate |
| GI | gastrointestinal |
| gm. | gram |
| gr | grain |
| gtt | drop |
| GU | genitourinary |
| GYN | gynecology |
| H/A | headache |
| hb, hgb. | hemoglobin |
| hct. | hematocrit |
| HEENT | head, eyes, ears, nose, throat |
| HL | heparin lock |
| HOB | head of bed |
| hosp. | hospital |
| Hr, hr | hour |
| H2O2 | hydrogen peroxide |
| H2O | water |
| H & P | history & physical |
| HR | heart rate |
| ht. | height |
| HTN, HBP | hypertension |
| Hx. | history |
| i, x1 | one |
| ICU | intensive care unit |
| I & D | incise and drain |
| IDDM | insuln dependent diabetes mellitus |
| ii, x2 | two |
| IM | intramuscular |
| Inc | incision |
| inf. | infusion |
| inj. | injection |
| I & O | intake and output |
| IPPB | intermittent positive pressure breathing |
| Irreg. | irregular |
| iss | one and one-half |
| IUD | intrauterine device |
| IV | intravenous |
| IVF | intravenous fluids |
| IVPB | intravenous piggy back |
| JCAHO | joint commission for accreditation of health care organizations |
| Kg, kg | kilogram |
| KUB | kidney, ureter, bladder |
| KVO, TKO | keep vein open |
| L | liter |
| L, lt | left |
| Lab | laboratory |
| lb, # | pound |
| LG | left gluteal |
| lg. | large |
| liq. | liquid |
| LLL | left lower lobe |
| LLE | left lower extremity |
| LLQ | left lower quadrant |
| LMP | last menstrual period |
| LOC | level of consciousness, laxative of choice |
| LOFA | loss of functional abilities |
| maew | moves all extremities well |
| mcg | microgram |
| M.D., MD | medical doctor |
| Med | medical, medicine |
| mEq | milliequivalents |
| mEq/L | milliequivalent per liter |
| mg, mgm | milligram |
| M.I., MI | myocardial infarction |
| ml | milliliter |
| mod. | moderate |
| NC, nc | nasal cannula |
| NG | nasogastric |
| NKA | no known allergies |
| Noct. | night time |
| NPO | nothing by mouth |
| NSR | normal sinus rhythm |
| Nsy | nursery |
| N & V | nausea and vomiting |
| NWB | non-weight bearing |
| o, os | orally, by mouth |
| O2 | oxygen |
| OB | obstetric |
| OBS | organic brain syndrome |
| occas. | occasional |
| OOB | out of bed (up and about) |
| OP | outpatient |
| OR | operating room |
| ORIF | open reduction and internal fixation |
| O.T. | occupational therapy |
| OTC | over the counter |
| Oz. | ounce |
| P | after |
| p.c. | after meals |
| PCN | penicillin |
| P.E. | pulmonary embolus, pulmonary edema, physical exam |
| PEARL | pupils equal and reactive to light |
| Ped. | pediatric |
| Per | by |
| PERRL | pupils equal, round, reactive to light |
| PERRLA | pupils equal, round, reactive to light with accommodation |
| P.I.D. | pelvic inflammatory disease |
| p.m. | afternoon |
| PMH | previous medical history |
| P.M.I. | point of maximal impulse |
| PND | paroxysmal nocturnal dyspnea |
| P.O. | phone order |
| po | by mouth |
| POD | postoperative day |
| Postop | postoperative |
| PP | postpartum |
| PPD | postpartal days |
| Prep | prepared for |
| prn | as needed |
| Psych. | psychiatric |
| Pt | patient |
| pt. | pint |
| P.T. | physical therapy |
| PT | prothrombin time |
| PTT | partial thromboplastin time |
| Q | every |
| Qh | every hour |
| Qid | four times a day |
| Qs | sufficient quantity |
| qt. | quart |
| R | rectal |
| RA | rheumatoid arthritis |
| RBC | red blood cell count |
| RDS | respiratory distress syndrome |
| Reg. | regular |
| Rh | rhesus blood factor |
| RLE | right lower extremity |
| RLL | right lower lobe |
| RLQ | right lower quadrant |
| RN | registered nurse |
| RNA | registered nurse anesthetist |
| ROM | range of motion |
| ROS | review of systems |
| RSR | regular sinus rhythm |
| R, rt. | right |
| R/T | related to |
| RTO | return to office |
| RUQ | upper right quadrant |
| Rx | prescriptiono, treatment |
| s | without |
| SGOT | serum gluconic oxalacetic transaminase |
| signif | significant |
| SL | sublingual |
| sm. | small |
| SOB | shortness of breath |
| sol. | solution |
| S/P | status post |
| spec. | specimen |
| SR ↓ | side rail down |
| SR ↑ | side rail up |
| ss | one-half |
| S & S, S/S | signs and symptoms |
| Staph. | staphylococcus |
| Stat | immediately |
| supp. | suppository |
| Surg. | surgery |
| Sym | symmetrical |
| T., tbs. | tablespoon |
| TAH | total abdominal hysterectomy |
| TBA | to be absorbed |
| TED | trademark for anti embolism |
| TED hose | antiembolism stockings |
| TEMP | temperature |
| tab | tablet |
| TENS | transcutaneous electrical nerve stimulation |
| TIA | transient ischemic attack |
| Tid | three times a day |
| TLC | tender loving care |
| TM | tympanic membranes |
| T & M | type and match |
| t.o. | telephone order |
| TPR | temperature, pulse, and respirations |
| t, tsp. | teaspoon |
| TURP | transurethral resectioin of prostate |
| TVH | total vaginal hysterectomy |
| TWB, TDWB | touchdown weight bearing |
| tx. | treatment |
| UA | urinalysis |
| U.T.I. | urinary tract infection |
| UO | urinary output |
| URI | upper respiratory infectio |
| Vag. | vaginal |
| vit. | vitamin |
| V.O., v.o. | verbal order |
| vol. | volume |
| Vs | visited |
| VS | vital signs |
| WBC | white blood cell count |
| W/C | wheel chair |
| WD | warm and dry |
| W.D., W.N., WD:WN | well developed, well nourished |
| WNL | within normal limits |
| W.O. | written order |
| Wt. | weight, weigh |
| W/U | workup |
| X | times |
| X-sect | cross section |
| yel. | yellow |
| y.o., y/o | years old |
| H.S. | half-strength, bedtime |
| S.C., S.Q. | sub-q, subcutaneous |
| D/C | discharge |
| A.D. | right ear |
| A.S. | left ear |
| A.U. | both ears |
| O.S. | left eye |
| O.D. | right eye |
| O.U. | both eyes |
| m | murmur |
| RL | ringers lactate |
| D5W | 5% dextrose in water |
| D5NS | 5% dextrose in water and normal saline |
| D51/2NS | 5% dextrose in water and 1/2 normal saline |
| NS | normal saline |
Created by:
whitneyjayde
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