Charting | Meaning |
@ | at |
a (line over it) | before |
a fib | atrial fibrillation |
abd | abdomen |
AB | abortions |
ABG | arterial blood gas |
ad lib | as often as desired |
ADL | activities of daily living |
AK | above the knee |
AKA | above the knee amputation |
amb | ambulatory |
amt | amount |
ant | anterior |
ante | before |
ASAP | as soon as possible |
BBB | bundle branch block |
BKA | below knee amputation |
BP or B.P. | blood pressure |
BM | bowel movement |
BR | bathroom |
BRP | bathroom privileges, up to bathroom only |
Bx | biopsy |
C1-7 | cervical vertebra |
C | Celsius/Centigrade |
c (line above) | with |
cath | catheter |
CBI | continuous bladder irrigation |
cm | centimeter |
C/O | complains of |
commode | bedside toilet |
DOA | dead on arrival |
dangle | sit at edge of bed, legs over side |
dc | discontinue |
decub | decubitis (lying) position |
DPT | Diptheria, Pertussis, Tetanus |
Drsg | dressing |
Dx | diagnosis |
exam | examination |
Ext. | extract/external |
F | Fahrenheit or female |
F.U.O. | fever of unknown origin |
FX | fracture |
ga | gauge |
GI | gastrointestinal |
GM | gram |
Grav (I, II,...etc.) | number of pregnancies, gravida |
GSW | gun shot wound |
G-Tube | gastric feed tube/ gastrostomy tube |
GU | genitourinary |
H & P | history and physical |
Hg | mercury |
H & H | hemoglobin and hematocrit |
Hb or Hbg | hemoglobin |
Hct. | hematocrit |
Htn | hypertendion |
ht | height |
Hx. | history |
H, hr. | hour, hours |
int | internal |
I & O | intake and output |
IUD | intra-uterine device |
irrig | irrigate, irrigation |
JVD | jugular vein distention |
kg | kilogram |
KUB | kidney, ureter, bladder (x-ray) |
L 1-5 | lumbar vertebrae or nerves |
LLE | left lower extremity |
LUE | left upper extremity |
L | left |
l | liter |
l/min | liters per minute |
lat | lateral |
lbs. | pound |
MRSA | methicillin resistant Staph. aureus |
mcg | microgram |
mEq or MEQ | millequivalent |
min | minute |
misc | miscellaneous |
ml | milliliter |
mm | millimeter |
mo | month |
mod | moderate |
NCB | no code blue |
NH | nursing home |
N & V | nausea and vomiting |
N.K.D.A. | no known drug allergies |
N.P.O. | nothing by mouth |
NSR | normal sinus rhythm |
N.T. | nasotracheal |
n/a | not applicable |
neg | negative |
O.J. | orange juice |
PCT | patient care technician |
P.E. | physical exam |
P.D. | postural drainage |
P.I. | present illness |
P.T.A. | prior to admission |
per | by or through |
PERL | pupils equal and react to light |
PERLA | pupils equal, react to light accommodation |
PERRLA | pupils equal, round reactive to light and accommodation |
PH | past history |
PND | paroxysmal nocturnal dyspnea |
PTD | prior to discharge |
PVC | premature ventricular contraction |
P | pulse |
p | after |
Post | posterior |
Prep. | preparation, prepare |
pt. | patient |
q | every |
qns | quantitiy not sufficient |
qs | quantity sufficient |
ques | question |
R | respirations |
R (circled) | right |
RAI | radioactive iodine |
RLE | right lower extremity |
R.L.Q. | right lower quadrant (abdomen) |
R/O | rule out |
ROM | range of motion |
ROS | review of systems |
RUE | right upper extremity |
RUQ | right upper quadrant (abdomen) |
Reg | regular |
Rbc | red blood cells |
Rx | recipe (prescription) |
S1-5 | sacral vertebra |
s | without |
sero-sang | sero-sanguinous |
Sl | slight |
Surg | surgery |
Sx | symptoms |
T1-12 | thoracic vertebra |
T | temperature |
ax | axillary |
o | oral |
r | rectal |
TMJ | temporomandibular joint |
TPR | temperature, pulse, respiration |
tx | treatment |
UE | upper extremity |
UGI | upper gastrointestinal |
umb | umbilical/umbilicus |
US | Ultra Sound |
V.O. | verbal order |
V.S. | vital signs |
vag | vaginal |
vent | ventilator |
VRE | vancomycin resistant enterococcus |
WNL | within normal limits |
wbc | white blood count |
w/c | wheelchair |
w/o | without |
wt | weight |
X | times |
Yell | yellow |
yest | yesterday |
y/o | years old |
yr. | year |
YTD | year to date |