Medical Terminology
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HOB | Head of bed
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Os | Mouth
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GI | Gastrointestinal
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GU | Genitourinary
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Fx | Fracture
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DM | Diabetes Mellitus
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MS | Multiple Sclerosis
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UTI | Urinary tract infection
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URI | Upper respiratory infection
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AIDS | Acquired Immune Deficiency Syndrome
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DNR | Do not recuscitate
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d/c *Make note that the letters are lower case* | Discontinue
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D/C *Make note that the letters are upper case* | Discharge
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et | And
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Hx | History
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NPO | Nothing by mouth
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PO | By mouth
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Px | Prognosis
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stat | At once
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w/c | Wheelchair
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p.c. | After meals
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h.s. | bedtime / hour of sleep
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noc | Night
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qd | Every day
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a.c. | Before meals
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(CVA) cerebrovascular accident | Stroke
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CHF | Congestive heart failure
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COPD | Chronic obstructive pulmonary disease
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(MI) myocardial infarction | Heart attack
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superior (cranial) | Toward the head
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inferior (caudal) | Toward the bottom / feet
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anterior (ventral) | Toward the front
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posterior (dorsal) | Toward the back
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medial | Toward the mid-line of the body
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lateral | Toward the side of the body
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internal (deep) | Away from the surface of the body
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external (superficial) | Toward the surface of the body
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proximal | Toward the main mass of the body
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distal | Away from the main mass of the body
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visceral | Related to internal organs
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parietal | Related to the body walls
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diaphragm | Separates the thoracic cavity and the abdominal cavity
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(RUQ) Right upper quadrant | Liver, gallbladder, duodenum, head of pancreas, right adrenal gland, upper lobe of right kidney, hepatic flexure of colon, section of ascending colon and transverse colon.
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(LUQ) Left upper quadrant | Left lower part of liver, upper lobe of left kidney, splenic flexure of colon, section of transverse and descending colon, stomach, spleen, pancreas, left adrenal gland.
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(RLQ) Right lower quadrant | Lower lobe of right kidney, section of ascending colon, right fallopian tube (female), right ovary (female), part of uterus (if enlarged), right spermatic cord (male), cecum, appendix, right ureter
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(LLQ) Left lower quadrant | Lower lobe of left kidney, section of descending colon, left spermatic cord (male), part of utuerus (if enlarged), sigmoid colon, left ureter, left ovary (female), left fallopian tube (female)
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Transverse plane | Plane separating the top half of the body from the bottom
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Frontal plane | Plane separating the front (ventral) half of the body from the back (dorsal) half
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Sagittal plane | Plane down the mid-line of the body separating the left side from the right side
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AAT | At all times
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AAROM | Active-Assistive Range of Motion
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A.D. | Right ear
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A.S. | Left ear
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ad. lib. | As desired
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ADL | Activities of daily living
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AEB | As evidence by
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A.E. | Adverse effects
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AKA | Above-the-knee amputation
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ALP | Assisted living program
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AMA | Against medical advice
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Amb. | Ambulate
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Amp. | Amputation
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Amt. | Amount
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AP | Apical pulse
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ATC | Around the clock
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AROM | Active range of motion
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ā | Before
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A.U. | Each ear
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BKA | Below-the-knee amputation
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bid | Twice each day
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BLE | Both lower extremities
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BLS | Basic life support
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BM | Bowel movement
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BP | Blood pressure
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BR | Bathroom
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BRP | Bathroom priviliges
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BUE | Both upper extremities
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"c" with a line over it | With
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cc | Cubic centimeter
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°C | Centigrade or Degrees Celsius
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CA | Cancer
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Cal. | Calorie
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Caps | Capsules
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CAT | Consistency as tolerated
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cath. | Catheter
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gtts. | Drops
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CDI | Clean, dry intact
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C/O | Complains of
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C + S | Culture and sensitivity
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CQI | Continuous quality improvement
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cm | centimeter
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CSM | Circulation, sensation, movement
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CPR | Cardio-pulmonary resuscitation
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CRF | Chronic renal failure
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CXR | Chest x-ray
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D&I | Dry and intact
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DS | Double strength
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DVT | Deep vein thrombosis
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Dx | diagnosis
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EC | Enteric coated
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ER | Emergency room
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°F | Degrees fahrenheit
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FBS | Fasting blood sugar
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FIM | Functional Independence measure
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FNP | Family Nurse Practitioner
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FROM | Full range of motion
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FWB | Full weight bearing
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gluc. | Glucose
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gm | Gram
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GNP | General Nurse Practitioner
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gr | Grain
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gtt. *Make note of the lowercase letters* | Drop
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MD | Medical Director
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HA | Hearing aid
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HCT | Hematocrit
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Hgb. | Hemoglobin
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H2O | Water
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HOB | Head of bed
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HOC | Hands on care
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HOH | Hard of hearing
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H&P | History and physical
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hr. | Hour
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ht. | Height
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HTN | Hypertension
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ie | Example
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IM | Intramuscular
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Indep | Independent
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INR | International Normalized Ratio
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IV | Intravenous
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I & O | Intake and output
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Kg. | Kilogram
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KVO | Keep vein open
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L | Liter
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L/min | Liters per minute
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Lab | Laboratory
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lb. | Pound
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LEs | Lower extremities
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lg | Large
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Lim. | Limited
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liq. | Liquid
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LLE | Left lower extremity
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LOC | Level of consciousness
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LOTA | Leave open to air
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LPN | Licensed Practical Nurse
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LROM | Limited range of motion
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LTC | Long term care
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Lt. | Left
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LUE | Left upper extremity
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LUQ | Left upper quadrant
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LLQ | Left Lower quadrant
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M | Meter
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MAR | Medical Administration Record
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Max | Maximal
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MDR | Main dining room
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MDS | Minimum data set
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Mcg | Microgram
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Meq | Milliequivalent
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Min. | Minimal
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mg | Milligram
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ml | Millileter
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mo | Month
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mod. | Moderate
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MOM | Milk of Magnesia
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mm | Millimeter
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ms *Make note of the lower-case letters* | Mechanical Soft (diet)
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MS | Multiple Sclerosis
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MT | Maintenance Therapy
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NAS | No added salt (diet)
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NC | Nasal Cannula
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NCS | No concentrated sweets (diet)
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NNO | No new order
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N.O. | New order
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NP | Nurse Practitioner
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NS | Normal saline
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NSG | Nursing
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NSR | Normal sinus rhythm
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N/V | Nausea and vomiting
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OBS | Organic brain syndrome
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occ. | Occasionally
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OOB | Out of bed
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OD | Right eye
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OS | Left eye
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OT | Occupational Therapy
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OTC | Over the counter
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OU | Both eyes
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oz. | Ounce
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O2 | Oxygen
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p | Pulse
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"p" with a line over it | after
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PEARL | Pupil equal, accommodating and reactive to light
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per | By
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S.O.B. | Shortness of breath
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POA | Power of attorney
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POC | Plan of care
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PP | Peripheral Pulses
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PRN | When necessary
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PROM | Passive range of motion
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PT | Physical Therapy / Prothrombin
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PTT | Partial thromboplastin time
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PWB | Partial weight bearing
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q | every
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QA | Quality assessment/assurance
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qd | Every day
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QI | Quality improvement
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qid | Four times a day
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QM | Quality management
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qod | Every other day
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qs | Every shift
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QS | Quality sufficient
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Q | Quart
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R | Respiration
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RAI | Resident assessment instrument
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RAP | Resident assessment protocol
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RBC | Red blood cell
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RCP | Resident care plan
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RDA | Recommended daily allowance
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Res. | Resident
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RLE | Right lower extremity
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RLQ | Right lower quadrant
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R/O | Rule out
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ROM | Range of motion
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RN | Registered nurse
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RRR | Regular rate and rhythm
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Rt or R | Right
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R/T | Related to
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RUE | Right upper extremity
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RUQ | Right upper quadrant
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RW | Rolling walker
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Rx | Prescription
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"s" with a line over it | Without
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S/A | Sugar and acetone
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SFP | Self feeding program
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SLB | Short leg brace
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sm. | Small
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SNF | Skilled nursing facility
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soln./sol | Solution
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S/P | Status post
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Spec. | Specimen
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SS | Social services
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SSE | Soap suds enema
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S.T. | Skilled therapy
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S/S | Signs and symptoms
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SQ | Subcutaneous
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Supp. | Suppository
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Susp. | Suspension
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T | Temperature
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T.O. | Telephone order
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tab | Tablet
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TAR | Treatment administration record
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Tbs. | Tablespoon
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TF | Tube feeding
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TIA | Transient ischemic attack
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tid | Three times a day
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TLC | Total lung capacity
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tol. | Tolerate
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TPR | Temperature, pulse, respiration
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tsp. | Teaspoon
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Tx | Treatment
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U/A | Urinalysis
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UDA | User defined assessment
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UDR | Unit dining room
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UEs | Upper extremities
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URI | Upper respiratory infection
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UTI | Urinary tract infection
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V.O. | Verbal order
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VS | Vital signs
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VSS | Vital signs stable
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WBC | White blood cell
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WBQC | Wide base quad cane
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W/C | Wheelchair
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WNFL | Within normal functional limits
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WNL | Within normal limits
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w/o | Without
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wt. | Weight
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x | Times
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↑ | Increased, elevated
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↓ | Decreased, reduced
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✓ | Check
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