Question | Answer |
PA & LAT CXR | Posterior(back) to anterior(front) and lateral(side) view chest x-ray |
MRI | Magnetic Resonance Imaging |
CT of C1 to L5 | Computerized tomography scan from first cervical vertebra to last lumbar vertebra |
Lateral | Side view or away from middle |
Proxium distal | closest to mid-line or medium |
Front | anti or ventrical |
Back | Posterial or dorsal |
injection sites | Gluteus Maximus(buttocks), Vastus lateralis(thigh muscle), Deltoid(shoulder muscle), Rectus abdominus(abdomen), Sternocleidomastoid(neck Muscle) |
Lumber Puncture | Needle puncture into the spinal canal to remove blood or fluid;looking for mentijitis |
VER | Visual evoked response |
AER | Auditory evoked response |
BAER | Brainstem auditory evoked response |
EEG | Electroencephalography - neurological test that measures the electrical signals the brain sends to body |
Immunity before Purity | Adrenal Gland |
Produces insulin | Pancreas |
Produces thyroidian T3 or T4 | Isthmus |
ECG/EKG | Electrocardiogram - a test to detect abnormal electric activity of the heart |
Echo | Echolcardiogram- an exam to study structure and motion of heart |
Holter Monitor | method of 24-hour continuous electrocardiogram to diagnose rhythm disturbances(wear this 24-hr) |
U/A | Urinalysis- looking for infection |
Cecum | Part of colon or large intestine |
u | unit |
iu | international unit |
qd | every day |
qod | every other day |
MS & MS04 | morphine sulfate |
MgS04 | Magnesium sulfate |
What to do to prevent an error | "When in doubt, write it out" |
abbreviation | a shortening of a word |
symbol | a written sign or character that is used to represent a word. |
tech | technician |
cath | Catherter |
cal or Kcal | Calorie |
gen | general |
BRP | Bathroom Privileges |
IV | intravenous |
US | Ultrasound |
CABG | Coronary Artery Bypass Graft |
stat | immediately |
Most medical abbreviations comes from what root language? | latin |
prn | as necessary or as needed |
ad lib | freely, as desired |
CNA | certified nursing assistant |
DO | doctor of osteopathy |
HUC or CHUC | Health Unit Coordinator or Certified Health Unit Coordinator |
LPN | licensed practical nurse |
LVN | licensed vocational nurse |
MD | medical doctor |
PCT | patient care technician |
RN | registered nurse |
Tech | technician |
ac | before meals |
ad lib | as desired |
asap | as soon as possible |
as tol | as tolerated |
bid | 2 times a day |
cont | continous |
dc | discontinue or discharge |
h, hr, hrs | hours |
hs | bedtime or hours of sleep |
midnoc or MN | midnight |
min | minute |
MR | may repeat |
nec | necessary |
pc | after meals |
prn | as necessary |
q | every |
q day | every day |
qh | every hour |
qid | 4 times a day |
qod | every other day |
rt | routine |
stat | immediately |
tid | 3 times a day |
amb | ambulatory |
BR | bedrest or bathroom depending on the facility |
BRP | bathroom privileges |
BSC | bedside commode |
CBR | complete bed rest |
OOB | out of bed |
act | activity |
qpm | is not bedtime or hours of sleep |
ax | axillary |
axillary | arm pit |
BP | blood pressure |
CMS | circulation, motion sensation (medicare services) |
I/O | intake/output |
NVS | neurological vital signs |
P | pulse |
R | respiration |
T | temp or temperature |
VS | vital signs |
wt | weight |
HOB | head of bed |
lt or l | left |
rt or R | right |
AE | antiembolism - blood clots, keeps circulation |
cath | catheter |
CBI | continuous bladder irrigation |
drsg | dressing |
irrig | irrigation |
NG | nasogastric (nose to stomach) |
SSE | soap suds enema |
st | straight |
TCDB | turn, cough, deep breathe |
TEDs | AE hose |
TWE | tapwater enema |
WMC | warm moist compress |
cc | cubic centimeter |
cm | centimeter |
gtts | drops |
g, gm, G, Gm | grams |
gr | grains 60 to 65 millograms |
mEq | milliequivalent |
mg | milligram |
ml, mL | milliliter |
cal or kcal | calorie |
cl | clear |
DAT | diet as tolerated |
FF | force fluids |
gen | general |
liq | liquids |
MN | midnight |
NAS | no added salt |
NPO | nothing by mouth |
reg | regular |
IM | intramuscular or into muscle (deltoid, glutitus |
INT | intermittent |
IVPB | intravenous piggyback |
po | by mouth |
subl | sublingual or under the tongue like nitro pill |
subq, sc, or sq | subcutaneous like insulin or heparian |
IV fluids | D/RL(dextrose Lactated ringers), D5W (dextrose 5%water), DW (dextrose/water), LR or RL(lactated ringers) |
D/RL | Dextrose Lactated Ringers |
D5W | Dextrose 5% Water |
DW | dextrose/water |
LR, RL | lactated ringers or ringers lactated |
H202 | hydrogren peroxide |
IV | intravenous |
NS, NSS, S | normal saline |
soln | solution |
TKO | to keep open |
KVO | Keep Veins Open |
p with - on top of it | after |
c with - on top of it | with |
/ | per |
check mark | check |
arrow pointing up | up |
arrow pointing down | down |
a triangle | change |
@ | at |
BRP | Bathroom Privileges |
BP | Blood Pressure |
I/O | Intake/Output |
PCT | Patient Care Technician |
LPN | Licensed Practical Nurse |
OT | Occupational Theraphy |
PT | Physical Theraphy |
Kardex | a profile of all current physicians' orders for a patient. |
medical staff | licensed physicians who have privileges to admit and attend to patients in the health care facility. |
medical transcription | translating from oral to written(on paper or electronically) the record of a person's medical record history, diagnosis,prognosis, and outcome |
physicians order sheet | a specific chart form used by the physician to record orders for the patient. |
transcription | procedure involving activating or communicating theplan of care that the physician determines for the patient. |
HIM | Health Information Management |
MAR | Medication Administration Record |
PRN | as necessary |
STAT | immediately |
T.O. | Telephone Order |
V.O. | Verbal Order |
Standing | Routine Orders |
One time or short order sheet | some meds can only be given for 72 hours. once or for just a specified short amount of time |
Kardex | profile of all current physicians orders for a patient. serves as one document where all orders are consolidated. |
bacteriology | study of bacteria that causes disease |
blood bank | dept of the laboratory (transfusion services) that is responsible for testing, preparing, providing blood and blood products |
chemistry department | performs tests to determine chemical changes in body fluids |
culture medium | special sustance that the specimen is place upon or in to allow bacteria to grow and multiply. |
cytology | study of cells |
donor services | dept of laboratory responsible for testing and collecting blood from donors. |
hematology | study of blood cells, coagulation, and bleeding disorders |
laboratory | dept that provides testing tohelp health care professional |
microbiology | study of microscopic organism. |
mycology | study of fungi that cause diseases |
parasitology | study of parasites that causes diseases. |
pathology | study of disease |
point-of-care stations | area set up with basic laboratory testing equipment to provide test results quickly, where the patient is located. |
serology department | dept responsible for the testing of specimens that produce a recordable reaction between an antibody and antigen |
specimen collection dept | department that obtains and processes all the specimens that arrived in the laboratory for testing. (lab) |
transport medium | a broad term used to describe what the specimen will be placed in to be sent to the lab |
urinalysis dept | processes the tests requested on urine specimens |
virology | study of viruses that cause disease. |
AIDS | Acquired Immunodeficiency Syndrome |
AFB | Acid-Fast Bacilli (TB Culture) |
Bili | Bilirubin (lacking yellow) |
BS | Blood Sugar (FBS - Fasting Blood Sugar) |
BUN | Blood Urea Nitrogen (Kidney Studies) |
CBC | Complete Blood Count (Blood Study) see hemoglobin |
CSF | Cerebrospinal Fluid (high Fever) |
Chol | Cholesterol (LDL & HDL) |
LDL | Bad Cholesterol (Low-Density Lipoprotein) |
HDL | Good Cholesterol (High-Density Lipoprotein) |
Creat | Creatine |
C & S | Culture and Sensitivity |
Diff | Differential |
FBS | Fasting Blood Sugar |
HbA1c, HgbA1C | Gylcosylated Hemoglobin (Diabetes do this test) |
Hgb | Hemoglobin |
HIV | Human Immunodeficiency Virus |
K | Potassium (Vitamin K - different drug) |
Mg | Magnesium |
Na | Sodium |
NPO | Nothing By Mouth |
RBC | Red Blood Count |
TSH, T3, T4 | Test to assess your thyroid gland TSH-Thyroid-Stimulating Hormone, T3- Triiodothyronine Resin Uptake, T-4 Thyroxine |
U/A | Urinalysis |
WBC | White Blood Count |
Glucose Meter | meter to determine blood sugar level |
Blood Samples | we just call lab, put in Bio hazard bag |
FE, FEs04 | Iron |
Hct | Hemotocrit |
Hgb | Hemoglobin |
Test for patient bleeding or on anticoagents | Prothrombin Time(PT), Partial Thromboplastin time (PTT), Fibrinogen Level(Fib), Platelet count (PLT CT, Clotting time, Thrombin clotting time (TCT) |
contrast medium | dye or iodine-containing substance that is injected into body illuminate inner structure that are hard to see.appears solid on xray |
Holter monitor | device that monitors heart activity throughout the course of the day. |
CXR | Chest X-ray |
ECG | Electrocardiogram |
Echo | Echocardiogram |
EEG | Electroencephalogram |
EGD | Esophagogastroduodenoscopy |
GI | Gastrointestinal |
EKG | Electrocardiogram |
invasive | procedure in which a part of body is entered, such as an incision cutting requires consent form |
HOH | Hard of Hearing |
IV | Intravenous |
IVP | Intravenous Pyelogram |
l | left |
MAR | Medication Administration Record |
MRA | Magnetic Resonance Angiography |
MRI | Magnetic Resonance Imaging |
Preps | Preparation for an Examination |
PROCTO | proctopscopy |
Sigmoid | Sigmoidoscopy |
UGI | Upper Gastrointestinal |
W/C | Wheel chair |
Transcribing a diagnostic exam order | When is exam performed, How is patient prepared, How is patient transported, Why is exam ordered, What dept performs the exam. |
Exam Performed | which test can be done right away |
Patient Prepared or prepped | may include diet change |
cardiology | heart test |
Cardiac catheterization | invasive procedure |
Echocardiogram (Echo) | non-invasive exam |
Electtrocardiogram | non-invasive exam |
Holter monitor | monitors heart activity over 24 hrs where the patient were electrodes. |
Telemetry | process of measuring and transmitting heart activity during hospitalization. |
Read entire order | prioritize and check for incomplete or illegible orders |
Prioritize Orders | what orders in order set need be transcribed first |
Medication in order set, copy to pharmacy | cruicial that pharmacy receive the physician medication orders |
Communicate the order to individual or departments | enter order for exam on paper requisition, send the requisition to dept and other facilities |
Record on Kardex | track orders, done in pencil and update as changes occur, discontinue or add. |
Record Medication on MAR | HUC responsible for writing medication on MAR |
Check off each order as set is completed | Place a check mark |
Reread and check all work for accuracy | multiply requests received by HUC |
Sign off order with name, title, date, and time | HUC accountable for orders transcribed |
AP | anterior to posterior, or front to back |
Decubitus | a position assumed when lying down |
Lat | lateral or side |
Oblique view | slanting angle |
CT | Computed tomography (CT) |
DSA | Digital Subtraction angiogram |
DVT | Digital Vascular Imaging |
fluoroscopy | allow for visualization of arteriess |
CT scan of abdomen | Computer tomography of the abdomen |
BE, BaE | Barium enema (test to view the large intestine) |
GB, OCG | Gallbladder, oral cholecystogram |
KUB | Kidneys, Ureters, Bladder |
mammogram | xray image of soft tissue of breast |
Nuclear Medicine | radioactive |
Ultrasound | use of high frequency sound to image internal structures |
bolus | large, single amount given all at once |
diet board | list of all depts patients and nutrition and meals ordered |
enteral | by way of intestine or gastrointestinal tract(goes through mouth to get to digestive tract) |
G-tube | Gastostomy tube - small plastic hose inserted in cut or incision in skin directly to stomach or small intestine |
NG-tube | Nasogastric tube- tube inserted in nose and routed directly into stomach |
parenteral | anything that bypass going thru mouth, IV or any injection |
tube feeding | IV, food in liquid form given through a tube that is inserted in stomach |
AS tol | as tolerated |
cc | cubic centimeters or chief complaint |
chol | cholesterol |
cl liq | clear liquids |
DAT | diet as tolerated |
K or KCL | potassium cholride |
NaCl | Sodium Chloride (salt) |
CDR | Commission Dietetic Registration |
Dietitians task | teach and recommend food choices and guidelines for patients on restricted diets |
nutrients | substance that provide body with energy and materials necessary for growth, maintenance of body tissues, proper cell functioning |
regular diets, general diet or house diet | given to a balance, nutritional dies with no restrictions |
Gen liq | General liquids |
Therapeutic | means tending to improve or restore health. |
Therapeutic diet | diet that modified to improve or treat specific conditions., ie over or under weight,diabetes |
ADA | American Dietetic Association diet - decrease the need for diabetic medication, control weight by managign calories and carb |
CHF | Congested Heart Failure |
Fluid Restricted | diet that controls or monitors liquids |
Calorie Controlled | may be ordered as a high-calorie or low calorie diet. |
Low Sodium or Low Salt diet | Lo Na or low NA; Lo NaCL; NAS (no salt added); 2gm Na (two grams sodium); 3.5 gm Na(three point five grams sodium) |
Pureed or blenderized | diet that breaks down the solid food into a liquid for ease of chewing/swalling(baby food) |
Renal | diet for patient with kidney disease, restricts proten, sodium(NA), potassium(K) and phosphorus(P OR PHOS) |
Special diets | Religious or cultural diets |
Supplement diets | food or drink that is fortified with additional nutrients and vitamins like Sustacal and Ensure |
cc means liquid form | True |
parental | apart/away |
diet board | to record patient diets, list of all of depts patients nutritrion and meals ordered |
Dietary service & diet orders can be requested via computer entry system and paper requistion | True |
Most diet orders are written as standing orders | True, they remain active or inplace until orders are written to change or discontinue |
NAS diet | No Added Salt diet |
activity | extent or level of body movement, function, or exercise |
afebrile | refers to body temperature within normal limits |
apical pulse | pulse taken over the chest in apex area ofheart |
axillary | refers to arm pit |
blood pressure | measure of pressure of blood sugar against wall of blood vessels |
diastolic | bottom value in blood pressure reading |
febrile | refers to elevated body temperature, not within normal range |
Kardex | communication tool used by HUC to communicate nursing orders to nursing staff |
neurological vital signs | signs used to assess the nervous system, inculde checking eye pupils for reaction |
nursing care | attention and treatment provided to client by clinical staff |
nursing care orders | orders written by the nurse |
nursing judgment | thought process |
palliative care | care given to patients near the end of life. diagnostic testing is stopped,most treatments are discontinued. |
pulse | heart is beating |
radial artery | artery located in wrist |
respirations | rate at which breathing occurs |
systolic | top value in blood pressure reading |
tympanically | refers to ear, temperature taken by ear (tympanic) |
vital signs | measurement of body's temperature, blood pressure, pulse, and respiration |
OOB | Out of Bed |
NVS | Neurological Vital Signs |
SSE | Soapsuds Enema |
RR | Respiratory Rate |
TWE | Tap Water Enema |
UO | Urinary Output |
TPR | Temperature, Pulse, Respiration |
tol | tolerated |
min | minutes |
F | fahrenheit |
D/c | discontinue |
C | Celsius |
CBR | complete Bed rest |
Amb | Ambulatory |
LOC | Level of consciousness |
normal temperature average | 98.6 degrees Fahrenheit or 37 degrees Celsius |
orthostatic blood pressure | reading be taken on patient in a lying, sitting, or standing position. |
Apical pulses | taken over chest in area of apex of heart using stethoscope. |
rr | respiratory rate recorded as breaths per minute |
P rate | Pulse rate recorded as beats per minute |
16 breaths per minute | average adult's respiration |
20 breaths a minute | average infants' respiration |
SOB | shortness of breath |
Neurological vital signs | checking the eye pupils for reaction to light, checking for Level of Consciousness (LOC) asking questions relating to time, place, and events. |
Position orders | for patients comfort |
log roll | roll used when turning the patient from side to side |
Enema | relieves gas(flatus), remove stool due to constipation, as a preparation for surgery or an exam. TWE, SSE, Oil retention, fleets |
Intravenous theraphy | provides nutrition, blood products, fluids, and medication to patient. |
NG | nasogastric tube another type of suctioning, if patient need stomach emptied |
Palliative care | providing pain relieff medications, nutritional supplements while at same time d/c alll diagnostic test and treatment, end of life. comfort care only no vital signs taken |
foot cradle | keeps the bedclothes off the feet and legs |
pressure mattress | reduces skin breakdown also called gaymar mattress |
sheepskin | adds barrier between the bedclothes and the patient. reduces skin breakdown |
BR | Bed Rest |
CBR | Complete Bed Rest |
apothecary | European term given to druggist, one who prepares or sell drugs |
chemical name | chemical & molecular formula of a drug |
generic name | common name given to drug by developer |
metric | modern measurement system based on meter, kilogram, and decimal system |
sliding scale | medication dose is written to be dependent on laboratory results |
trade or brand name | name given to drug by the manufacturer or seller |
ASA | aspirin |
Aer | Aerosol |
cap | capsule |
chew | chewable |
CNS | Central nervous system |
Conc | concentrate |
CSA | Controlled Substance Act |
CVC | Central Venous Catheter |
D5 | Dextrose 5% |
D5W | Dextrose 5% Water |
DEA | Drug Enforcement Administration |
dr | delayed release |
dr | dram |
drsg | dressings |
effrv | Effervescent |
elcon | Electronically Controlled |
er | extended Release |
g, gm, | gram |
gr | grain |
gran | granule |
gtt | drop |
H | Hypodermic |
h, hr | hour, |
HA or Hyperal | Hyperalimentation |
Hep loc | Heparin Lock |
hs | hour of sleep or bedtime |
ID | Intradermal |
IM | Intramuscular |
imp | implant |
inj | injection |
INT | Intermittent IV needle |
IVPB | Intravenous piggyback |
L, l | liter |
loz | lozenge |
mcg | microgram |
mEq | milliequivalent |
met | metered |
mg | milligram |
ml | milliliter |
MOM | Milk of Magnesia |
NaCl | Sodium Chloride (saline) |
NF | National Formulary |
NS | Normal Saline |
NSAID | Nonsteroidal Anti-inflammatory Drug |
oz | ounce |
PCA | Patient-controlled analgesia |
PDR | Physician's Desk Reference |
PICC | Peripherpherally Inserted Central Catheter |
po | oral, or by mouth |
prn | as necessary |
pwd | powder |
subling,subl | sublingual |
susp | suspension |
supp | suppository |
tab | tablet |
Tpn | Total Parenteral Nutrition |
USP | United States Pharmacopeia |
VAD | Vascular Access Device |
Oz and cc | apothecary means ounces; and cc means in metric |
(gr) xv | means 15 grains |
apothecary symbols | gr for grain, dr for dram, and oz for ounce |
cap er | capsule extended release |
Aer met | Aerosol metered |
oint | ointment |
tab dr | tablet delayed release |
common unit of measurement for weight | gram, liter, or cubic centimeter.Q12hr |
Q12hr | Every 12 hours |
elix | elixir |
o.u. | both eyes |
o.s. | left eye |
O.d. | right eye |
p.r. | per rectum or rectally |
A.D. or A.R. | Right Ear |
A.S. or A.L. | Left Ear |
A.U. | Both ears |
NJ | nasojejunal tube |
noct | night |
et | and |
ss | one half |
aq or H2) | water |
qs | quantity sufficient |
s with line over it | without |
c with a line over it | with |
p with line over it | after |
a with line over it | before |
3 teaspoon | equals 5 ml |
3 tablespoon | equals 15 ml |
1 gram | equals 1000mg |
1 kiliogram | equals 1000 grams |
1 milliliter | equals 1 cc and 0.001L |
1 cc | equals 1 ML and 0.001L |
1 liter | equals 1000ml |
1 tablespoon | equals 15cc |
30cc | equals 1 ounce |
gr i | equals 60 or 65 mg |
NKDA | No known Drug Allergies |
NHO | Notify House Officer |
SBP | Systolic Blood Pressure |
TCDB | Turn, cough, deep breath |
DBP | Diastolic Blood Pressure |
ETOH | Alcohol |
IP | inpatient |
IPPB | intermittent positive pressure |
IU | International unit |
IUD | intrauterine device |
IUP | intrauterine pregnancy |
IVF | intravenous fluids |
IVR | intravenous rate |
K+level | Potassium Level |
KO | keep open |
L.A. | long acting |
LAS | label as such |
LDH | lactodehydrogenase |
LE | lupus Erythematosus |
LFT | liver function test |
LOA | leave of absence |
LOC | laxative of choice |
LPN | licensed practical nurse |
lytes | Electrolytes |
M & M enema | milk and molasses enema |
Mcg or mcg | Micrograms |
meds | medications |
MI | Myocardial Infraction (heart attack) |
mm | millimeter |
ml | milliliter |
MN, mn, NOC | midnight |
N, NL | normal |
narc | narcotics |
N.B. | note well, take notice |
NBN | Newborn nursey |
NC | nasal cannula |
NDC | national Drug Code |
NF | National Formulary |
NH | nursing home |
NICU | newborn intensive care unit |
NKA | no known allergies |
NKMA | no known medication allergy |
NKDA | no known drug allergies |
nst | not sent |
n/v | nausea and vomiting |
O | pint |
OB | obstetrics |
OD | overdose |
oint | ointment |
OJ | Orange Juice |
OOB | Out of Bed |
OP | outpatient |
opth | ophthalmic |
OR | operating room |
P or p | after, per |
P.A. | prolonged action or Physician Assistance |
CCU | coronary care unit |
CDS | controlled drug substance |
CICU | coronary intensive care unit |
CLD or CL diet | clear liquid diet |
cond | condition |
cont | continous |
C section | Cesarean section |
CSF | cerebral spinal fluid |
CVA | cerebrovascular accident or stoke |
CXR | Chest Xray |
cysto | cystoscopy |
D.A. | delayed action |
decub | decubitus, xray or bedsore |
dig | digoxin |
dig level | digoxin Blood level |
DNI | Do not Intubate |
DNR | Do not Resusciate |
DR | Delivery |
DS | Double Strength |
Dx | diagnosis |
E.C. | enteric coated |
ER | Emergency Room |
FDA | Food and Drug Administration |
Fi02 | frequency of inspired air |
FS | floor stock |
FTT | failure to thrive |
FUO | fever of unknown origin |
Fx | fracture |
f(x) | function |
GFR | glomerular filtration rate |
GU | genitourinary |
GYN | gynecology |
H.A. or HA | headache |
HCL | hydrochloride |
HCVD | hypertensive cardiovascular disease |
HEENT | head, eye, ear, nose, throat |
hep lock or H.L. | heparin lock |
Hg | mercury |
Hgb | hemoglobin |
H.O. | house officer |
H.R. | heart rate |
Hx | history |
Hyperal | hyperalimentation |
ICN | intensive care nursery |
ICU | intensive care unit |
gluc | glucose |
IV sites | Intraderma, Intravenous, Subcutaneous, Intramuscular |