| a |
before (ante) |
| a fib. |
atrial fibrillation |
| a. tach. |
atrial tachycardia |
| a.c. or a/c |
before meals |
| A.D.L. |
Activities of Daily Living |
| AROM |
artificial rupture or membranes |
| A.S.A.P. |
as soon as possible |
| A.T. |
Activity Therapy |
| aa |
of each |
| AA |
Alcoholics Anonymous |
| Ab |
abortion |
| abd |
abdomen |
| ABG |
arterial blood gases |
| ABP |
arterial blood pressure |
| AD |
right ear |
| ad lib |
as desired |
| ADA |
American Diabetic Association |
| adm. |
admitted (admission) |
| alc |
alcohol |
| alt |
alternate |
| AM |
morning |
| AMA |
against medical advice |
| amb |
ambulatory |
| amt |
amount |
| angio |
angiogram |
| ant |
anterior |
| APC |
Aspirin - Phenacetin - Caffeine |
| approx. |
approximately |
| appt. |
appointment |
| aq. |
water (aqueous) |
| art. |
artery |
| as tol |
as tolerated |
| ASA |
acetyl salicylic acid (aspirin) |
| AWOL |
absent without leave |
| Ax |
axilla |
| b.i.d. (BID) |
twice a day |
| B/P |
blood pressure |
| BE |
barium enema |
| blad |
bladder |
| BM |
bowel movement |
| BP |
blood pressure |
| BUN |
blood urea nitrogen |
| Bx |
behavior |
| C |
centigrade |
| c |
with |
| c.M. or CM |
certified midwife |
| C.N.M. or CNM |
certified nurse midwife |
| C.S. |
central service |
| c/o |
complains of |
| ca |
cancer |
| ca. or calc. |
calcium |
| CABG |
coronary artery bypass & graft |
| cal |
calorie |
| cap. |
capsule |
| card. |
computerized axial tomography |
| CAT |
CT scan |
| CBC |
complete blood count |
| CC |
chief complaint |
| cc |
cubic centimeter |
| chol. |
cholesterol |
| CL |
chloride |
| clav. |
clavicle |
| cm |
centimeter |
| CNS |
central nervous system |
| CO2 |
carbon dioxide |
| comf |
comfortable |
| conc |
concentrate |
| cons |
consultation |
| cont |
continued |
| contrib |
contributory |
| COPD |
chronic obstructive pulmonary disease |
| COR 0 |
acute heart stoppage |
| cpd |
compound |
| CPM |
certified professional midwife |
| CPR |
cardio-pulmonary resuscitation |
| cran |
cranial |
| CSF |
cerebral spinal fluid |
| CVA |
cerebrovascular accident (stroke) |
| D & C |
dilatation & curettage |
| D.C. |
Doctor of Chiropractic |
| D.O. |
Doctor of Osteopathy |
| D/C |
discharge |
| d/c |
discontinue |
| D5W |
dextrose 5% in water |
| DD |
date dictated |
| decr |
decreased |
| defib |
defibrillation |
| DEM |
direct entry midwife |
| depr |
depressed |
| Diff |
differential |
| dil |
Dilute |
| dis |
disease |
| dist |
distal |
| dk |
drunk |
| dl |
deciliters |
| DOA |
dead on arrival |
| DOB |
date of birth |
| dr |
dram |
| Dr. |
doctor |
| DS |
discharge summary |
| DTR's |
deep tension reflexes |
| DT's |
delirium tremens |
| Dx |
diagnosis |
| ECT |
electroconvulsive therapy |
| EDD |
estimated due date |
| EEG |
electroencephalogram |
| EENT |
eyes, ears, nose & throat |
| EKG |
electrocardiogram |
| elev |
elevate |
| ENT |
ears, nose & throat |
| EOM |
extraoccular muscles (movements) |
| ER |
emergency room |
| EST |
electric shock treatment |
| EtOH |
ethyl alcohol |
| etx. |
external |
| extr |
extremities |
| f/u |
follow up |
| fa |
father |
| FBS |
fasting blood sugar |
| FHT |
fetal heart tones |
| fl |
fluids |
| ft. |
foot |
| FUO |
fever of unknown origin |
| Fx |
fracture |
| g or gm |
gram |
| GB |
gall bladder |
| gen |
general |
| genit |
genitalia |
| GI |
gastrointestinal |
| gluc |
glucose |
| gp |
group |
| gr. |
grain |
| grav. |
gravid |
| GSW |
gun shot wound |
| GTT |
glucose tolerance test |
| gtt. |
drop |
| gtts. |
drops |
| GU |
genitourinary |
| gyn |
gynecology |
| h |
hour |
| H2O |
water |
| H2O2 |
Hydrogen Peroxide |
| HA |
headache |
| hb |
husband |
| Hbg |
Hemoglobin |
| Hct |
hematocrit |
| HCVD |
hypertensive cardiovascular disease |
| Hd. |
head |
| HEENT |
head, eyes, ears, nose & throat |
| hern |
herniated |
| HR |
heart rate |
| hr |
hour |
| HS |
hour of sleep |
| ht |
height |
| hx |
history |
| hyst |
hysterectomy |
| I & D |
incision & drained |
| I & O |
intake & output |
| I.C. |
initial contact |
| id |
in diem (during the day) |
| IM |
intramuscular |
| inj |
injured |
| inpt. |
inpatient |
| int |
internal |
| IPPB |
intermittent positive pressure breathing |
| irreg |
irregular |
| irrig |
irrigate |
| IV |
intravenous |
| IVP |
intravenous pyelogram |
| K+ |
potassium |
| kg |
kilogram |
| KUB |
kidneys, ureters, & bladder |
| L |
left |
| L & A |
light & accommodation |
| LMP |
last menstrual period |
| L.P.N. |
licensed practical nurse |
| lab |
laboratory |
| lac |
laceration |
| lap |
laparotomy or laporoscopy |
| lat |
lateral |
| lb |
pound |
| LE |
lower extremities or Lupus Erythematosus |
| Leuc |
leukocytes |
| Lg |
large or leg |
| lig |
ligament |
| liq |
liquid |
| LLQ |
lower left quadrant |
| LOA |
leave of absence or left occiput anterior |
| LOP |
left occiput posterior |
| LP |
lumbar puncture |
| LUQ |
left upper quadrant |
| lymphs |
Lymphocytes |
| M.D. |
Doctor of Medicine, physician |
| m.s. |
multiple sclerosis, morphine sulphate |
| M.T. |
movement therapy |
| max |
maximum |
| MCH |
mean corpuscular hemoglobin |
| MCHC |
mean corpuscular hemoglobin concentration |
| MCV |
mean corpuscular volume |
| med |
medical |
| meds |
medicines |
| mEq/1 |
milliequivalent per liter |
| mg |
milligram |
| MI |
myocardial infarction (heart attack) |
| ml or mL |
milliliter |
| mm |
millimeter |
| mo |
mother |
| MR |
mental retardation |
| MR# |
medical record number |
| NA |
not available |
| N/A |
not applicable |
| Na+ |
sodium |
| NBS |
no bowel sounds |
| neg |
negative |
| ng |
naso-gastric |
| NKA |
no known allergies |
| NMR |
nuclear magnetic resonance |
| No. |
number |
| Noct |
night |
| norm |
normal |
| NPN |
non-protein nitrogen |
| NPO |
nothing by mouth |
| nullip |
nulleparous (no pregnancies) |
| O2 |
oxygen |
| OA |
occiput anterior |
| o.d. |
once a day |
| O.T. |
occupational therapy |
| OB |
obstetrics |
| OBS |
organic brain syndrome |
| OD |
right eye |
| od |
overdose |
| OP |
occiput posterior |
| opd |
out-patient department |
| ops |
operations |
| OR |
operating room |
| orth |
orthopedic |
| OS |
left eye |
| OU |
both eyes |
| outpt |
outpatient |
| oz |
ounce |
| P |
after |
| P & A |
percussion & auscultation |
| P.E. |
physical examination |
| P.I.D. |
pelvic inflammatory disease |
| p.o. |
by mouth |
| PA |
postero-anterior |
| palp |
palpated |
| PBI |
protein bound iodine |
| pc |
after meals |
| pdr |
powder |
| ped |
pediatrics |
| pen |
penicillin |
| per |
by |
| PERLA |
pupils equal reactive to light & accommodation |
| pH |
measure of acidity or alkalinity |
| Ph.D. |
Doctor of Philosophy |
| phys |
physical |
| PM |
afternoon |
| PN |
progress note |
| pneu |
pneumonia |
| pos |
positive |
| post |
posterior |
| postop |
postoperative, after surgery |
| PPD |
purified protein derivative |
| preop |
preoperative, before surgery |
| prep |
prepare for |
| prev |
previous |
| prn |
whenever necessary |
| pros |
prostate |
| prox |
proximal |
| Psy. Ser. |
psychological services |
| PT |
physical therapy |
| pt |
patient |
| pvc |
preventricular contraction |
| pwd |
powder |
| q |
every |
| q.__h |
every ____ hour |
| q.d. |
every day |
| q.h. |
every hour |
| q.i.d. |
four times a day |
| q.n. |
every night |
| q.o.d. |
every other day |
| QA |
quality assurance |
| QAC |
quality assurance coordinator |
| QAP |
quality assurance program |
| QAR |
quality assurance review |
| qns |
quantity not sufficient |
| R |
right |
| (R) |
refused |
| R.D. |
registered dietician |
| R.N. |
registered nurse |
| R.O. |
reality orientation |
| ROA |
right occiput anterior |
| ROP |
right occiput posterior |
| R.T.P. |
recreational therapeutic pass |
| R/O |
rule out |
| rad |
radial |
| RBC |
red blood (cell) count |
| rbc |
red blood cells |
| rect |
rectal |
| Rh |
rhesus blood factor |
| RLQ |
right lower quadrant |
| ROS |
review of systems |
| RR |
respiratory rate |
| RUQ |
right upper quadrant |
| Rx |
prescription, take |
| s |
without |
| S.H. |
state hospital |
| S/A |
sugar & acetone |
| Sa |
saline |
| Schiz. |
schizophrenia |
| sed rate |
erythrocyte sedimentation rate |
| serol |
serology |
| SGOT |
serum glutamic oxalacetic transaminase |
| SGPT |
serum glutamic pyruvic transaminase |
| sibs |
siblings |
| SIDS |
sudden infant death syndrome |
| sig |
to write, to take |
| sl |
slight |
| SOAPE |
subjective, objective, assessment, plan, evaluation |
| SOB |
shortness of breath |
| Soc. hx |
social history |
| Soc. Ser. |
social service |
| sol |
solution |
| sos |
when necessary |
| sp |
spine |
| sp. cd. |
spinal cord |
| sp. fl. |
spinal fluid |
| sp. gr. |
specific gravity |
| Spec. |
specimen |
| SQ |
subcutaneous |
| SROM |
spontaneous rupture of membranes |
| Staph |
staphylococcus |
| stat |
immediately |
| Strep |
streptococcus |
| subcut |
subcutaneous |
| sup |
superior |
| Surg |
surgery |
| Sx |
symptoms |
| sys |
system |
| T & A |
tonsillectomy & adenoidectomy |
| T.A. |
therapeutic assignment |
| t.i.d. |
three times a day |
| T.O. |
telephone order |
| tab |
tablet |
| TB |
tuberculosis |
| tbsp. or T. |
tablespoon |
| temp. |
temperature |
| thor |
thorax |
| thromb |
thrombosis |
| TLC |
tender loving care |
| TM |
tympanic membrane (eardrum) |
| TP |
treatment plan |
| TPR |
temperature, pulse, respiration |
| tsp. or t. |
teaspoon |
| tx |
treatment |
| U.O. |
urinary output |
| u/o |
under observation |
| UA |
urinalysis |
| UGI |
upper gastrointestinal series (x-ray) |
| UNK |
unknown |
| URI |
upper respiratory infection |
| UTI |
urinary tract infection |
| V. fib. |
ventricular fibrillation |
| V. tach. |
ventricular tachycardia |
| V.O. |
verbal order |
| vag |
vaginal |
| VC |
vital capacity |
| VD |
venereal disease |
| VDRL |
serological test for syphilis |
| vit. |
vitamin |
| vol |
volume |
| VS |
vital signs |
| WBC |
white blood (cell) count |
| wbc |
white blood cell |
| wd |
well developed |
| wf |
wife |
| wk |
week |
| wn |
well nourished |
| WNL |
within normal limits |
| wt. |
weight |
| x |
times |
| x-ray |
radiology |
| y/o |
year old |
| yrs |
years |