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N371 Abbreviations

Medical Documentation Abbreviations

QuestionAnswer
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