Copyright held by The John Cooke Fraud Report. Reprint rights are granted with attribution to The John Cooke Fraud Report with a link to this website.
MEDICAL NOTES HAVE A LANGUAGE ALL THEIR OWN.
The Joint Commission for Accreditation of Healthcare Facilities requires that each facility maintain a list of approved acronyms, abbreviations and symbols. Upon request, the facility should be able to supply you with a list of those that they use. Some may have more than one meaning, so context is important. Just like the English language, words may be added or deleted. So it is with the language of medicine. Make note the dates on notes that come from very old records, as usage/meaning may have changed since they were recorded. Drug names are not to be abbreviated (the two exceptions are ASA and HCTZ), however vitamin abbreviations are allowed.
| Ç before (ante) |
| Çc before meals |
| AAA abdominal aortic aneurysm, acute anxiety attack |
| AAAAA aphasia, agnosia, apraxia, agraphia, alexia |
| ACE angiotensinconverting enzyme |
| ACLS advanced cardiac life support |
| AD admitting diagnosis |
| ADH antidiuretic hormone |
| ADL activities of daily living |
| AH abdominal hysterectomy |
| AHD arteriosclerotic heart disease |
| AIDS acquired immune deficiency syndrome |
| AK above the knee |
| AKA above the knee amputation |
| AMA against medical advice; |
| American Medical Association |
| AMI acute myocardial infarction |
| ANP advanced nurse practitioner |
| ARC AIDS related complex |
| ARF acute renal failure |
| ARI acute respiratory infection |
| ARDS adult respiratory distress syndrome; acute respiratory distress syndrome. art arterial |
| ATN acute tubular necrosis |
| ASA aspirin |
| ASCVD arteriosclerotic cardiovascular disease |
| ATN acute tubular necrosis |
| Aus© auscultation |
| A&W alive and well |
| BG blood glucose |
| bid twice daily |
| Bil(at) bilateral |
| BK below knee |
| BKA below the knee amputation |
| BLE both lower extremities |
| BM bowel movement; bone marrow |
| B/O because of bol bolus |
| BP blood pressure; bathroom privileges; bedpan |
| BPH benign prostatic hypertrophy bronch bronchoscopy; bronchoscope |
| BS blood sugar |
| BSA body surface area |
| CA cancer, carcinoma |
| CAB coronary artery bypass |
| CABG coronary artery bypass graft |
| CAD coronary artery disease |
| CAT computerized axial tomography cath catheter, catheterize |
| CC chief complaint; complications and comorbidities |
| CCU cardiac care unit, coronary care unit |
| CEU continuing education unit |
| CICU cardiac (coronary) intensive care unit |
| CHF congestive heart failure |
| CAPD continuous ambulatory peritoneal dialysis |
| CKD chronic kidney disease |
| COPD chronic obstructive pulmonary disease |
| CP chest pain |
| CPAP continuous (constant) positive airway pressure |
| CRF chronic renal failure |
| CSF cerebrospinal fluid |
| CVA cerebrovascular accident |
| CVD cardiovascular disease |
| CXR chest xray |
| DAT diet as tolerated |
| DC, dc discontinue |
| DD differential diagnosis decub lying down (decubitus |
| DM diabetes mellitus |
| DNR do not resuscitate |
| DOB date of birth |
| DOA date of admission |
| DOE dyspnea on exertion |
| Decub decubitus ulcer |
| DRG Diagnosis Related Group |
| DSM Diagnostic and Statistical Manual (Mental Disorders) |
| DT delirium tremens |
| DVT deep vein thrombosis |
| DW distilled water; dry weight |
| Dx diagnosis |
| EBL estimated blood loss |
| EC enteric coated |
| ECF extended care facility |
| Echo echocardiogram |
| E coli Escherichia coli |
| ECMO extracorporeal membrane oxygenation |
| ECV extracellular volume |
| ECW extracellular water |
| ED emergency department |
| EDC estimated date of confinement edent edentulous |
| EEG electroencephalogram |
| EENT eye, ear, nose, throat |
| EEP end expiratory pressure |
| EF ejection fraction |
| EFA essential fatty acids |
| EGA estimated gestational age |
| EKG electrocardiogram |
| ELISA enzyme linked immunosorbent assay (immunological testing) |
| EN enteral nutrition |
| EOB explanation of benefits |
| EOMB explanation of medical benefits |
| EPAP expiratory positive airway pressure |
| EPI epinephrine |
| EPO erythropoietin |
| EPS extrapyramidal symptoms |
| ESLD end stage liver disease |
| ESRD end stage renal disease |
| ET endotracheal tube |
| ETD estimated time of death |
| Etiol etiology |
| ETOH ethyl alcohol |
| Exp expired |
| F female |
| FBG fasting blood glucose |
| FAS fetal alcohol syndrome |
| FBS fasting blood sugar |
| FOB foot of bed |
| FTN full term nursery |
| FTP failure to progress |
| FTT failure to thrive |
| F/O followup |
| FUO fever of undetermined origin |
| Fx fracture |
| GALT gut associated lymphoid tissue |
| GB gallbladder |
| GBD gallbladder disease |
| GBS gallbladder series |
| GC gonococcus |
| GERD gastroesophageal reflux disease |
| GFR glomerular filatration rate |
| GI gastrointestinal |
| G gravida |
| GSW gunshot wound |
| GU gastric ulcer, genitourinary |
| HA headache |
| HCO3 bicarbonate |
| HCTZ hydrochlorothiazide |
| HDN hemolytic disease of the newborn |
| HD hemodialysis |
| HEENT head, eyes, ears, nose, and throat |
| hemi hemiplegia, hemiplegic |
| HH hiatal hernia |
| HHNKS hyperglycemic, hyperosomolar nonketotic syndrome |
| HI head injury |
| HIV hum immunodeficiency virus |
| HL hearing loss |
| HLHS hypoplastic left heart syndrome |
| H&N head and neck |
| H&P history and physical |
| H/O; h/o history of |
| HOB head of bed |
| HOH hard of hearing |
| HR heart rate |
| hs bedtime |
| Htn hypertension |
| Hx history |
| IBD inflammatory bowel disease |
| IBS irritable bowel syndrome |
| ICW intracellular water |
| IGT impaired glucose tolerance |
| IHD ischemic heart disease |
| INH isoniazid |
| I & O intake and output |
| IUGR intrauterine growth retardation |
| IVP intravenous pyelography; intravenous push |
| IVPB Intravenous piggyback |
| ISVD interventricular septal defect |
| JCAHO Joint Commission on Accreditation of |
| Healthcare Organizations |
| K potassium |
| KCl potassium chloride |
| KDC infant warming bed |
| KLS kidney, liver, spleen |
| KVO keep vein open (IV rate of usually 25 cc/hr with |
| NS or D5W) |
| KUB kidney, ureter, bladder |
| lap laporotomy |
| LBW low birth weight |
| LCSW licensed clinical social worker |
| LES lower esopohageal spinchter |
| LFT liver function tests |
| LGA large for gestational age |
| LLQ lower left quadrant |
| LMP last menstrual period |
| LOC laxative of choice (unacceptable abbreviation); |
| level of consciousness |
| LOS length of stay |
| LP lumbar puncture |
| LR lactated ringers |
| LRQ lower right quadrant |
| LTC long term care |
| LVH left ventricular hypertrophy |
| lytes electrolytes |
| M Male, married |
| MAOI monamine oxidase inhibitor |
| MDD major depressive disorder |
| mec meconium |
| medsurg medicalsurgical |
| mEq milliequivalents |
| mEq/L milliequivalents per liter |
| met(s) metastasis, metastasize, metastasizing |
| MI myocardial infarction |
| MICU medical intensive care unit |
| mM millimole |
| M&M morbidity & mortality |
| mmHg millimeters of mercury (BP unit) |
| MO mineral oil; months old |
| MOM milk of magnesia |
| Mono monocyte; mononucleosis |
| Mosm milliosmol |
| MR magnetic resonance; medical records; mental retardation |
| MRSA methicillin resistant staph aureus |
| MRI magnetic resonance imaging |
| MS mitral stenosis; multiple sclerosis |
| MSW Master of Social Work |
| MT medical technologist |
| MVA motor vehicle accident |
| MVP mitral valve prolapse |
| N/A not available |
| NAD no acute distress |
| NAS no added salt |
| NEC necrotizing enterocolitis |
| NG(T) nasogastric (tube) |
| NH(P) nursing home (placement) |
| NKA no known allergies |
| Nl normal |
| NOS not otherwise specified; no organisms seen |
| NPO nil per os (nothing by mouth) |
| NS normal saline; neurosurgery |
| NSAID nonsteroidal antiinflammatory drug |
| N & V nausea and vomiting |
| NVD nausea, vomiting, diarrhea |
| OB obstetrics |
| OBS organic brain syndrome |
| OC oral contraceptive |
| OOB out of bed |
| OR operating room |
| Ortho orthopedics |
| O2 sat oxygen saturation |
| OT occupational therapy |
| OTC over the counter |
| p post; after |
| P para; phosphorus; pulse |
| PA pernicious anemia; Physician’s Assistant |
| P&A percussion and auscultation |
| PACU postanaesthesia care unit |
| Para para (nullipara, primiparia, Para !, Para II, etc) |
| Path pathology |
| p.c. after meals |
| PCA patient controlled analgesia |
| PVN penicillin |
| PCOD polycystic ovarian disease |
| PDA patent ductus arteriosus |
| PE pelvic exam; physical exam |
| PEEP positive endexpiratory pressure |
| PEG percutaneous endoscopic gastrostomy |
| PERRLA pupils equal, round, reactive to light and accommodation |
| PFT pulmonary function test |
| PH past history |
| PT physical therapy |
| PTA prior to admission/arrival |
| PICC peripherally inserted central catheter |
| PIP positive inspiratory pressure |
| PKU phenylketonuria |
| PMH past medical history |
| PN parenteral nutrition |
| PO; po per os (by mouth); phone order |
| POD# postoperative day# |
| Postop postoperative |
| PP postpartum; postprandial |
| PPBS postprandial blood sugar |
| PR; pr per rectum |
| Preop preoperative |
| PRN pro re nata (as necessary) |
| Prog prognosis; progress |
| PSA prostate specific antigen |
| PTA prior to admission |
| PUD peptic ulcer disease |
| Pulm pulmonary |
| PVC premature ventricular contraction |
| P/Y; PY pack year (cigarettes) |
| q every |
| QH; qh every hour |
| R rectal; respiration; right |
| RA rheumatoid arthritis; right atrium; room air |
| Resp respiratory; respiration |
| RDS respiratory distress syndrome |
| Re concerning |
| Rh rhesus factor (will be + or ) |
| RIA radioimmunoassay |
| RLE right lower extremity |
| RLL right lower lobe |
| RLQ right lower quadrant |
| RN registered nurse |
| R/O rule out |
| ROM range of motion; rupture of membranes |
| ROS review of symptoms |
| RQ respiratory quotient |
| RR respiratory rate; recovery room |
| RRR regular rate and rhythm |
| RT respiratory therapist; radiation therapy |
| RUE right upper extremity |
| RUQ right upper quadrant |
| Rx prescription, take, therapy, treatment |
| s without |
| SAH subarachnoid hemorrhage |
| SB small bowel; short bowel |
| SBE shortness of breath on exertion, |
| subacute bacterial endocarditis |
| SBO small bowel obstruction |
| SC sickle cell |
| SCN special care nursery |
| SGA small for gestational age |
| SIADH syndrome of inappropriate antidiuretic hormone |
| SIDS suddeninfant death syndrome |
| SLE systemic lupus erythematosus |
| SNF skilled nursing facility |
| SO significant other |
| S/O signed out |
| SOAP subjective, objective, assessment, plan |
| SOB shortness of breath |
| Sol solution |
| S/P; s/p status post |
| SQ subcutaneous |
| S&S, S/S signs and symptoms |
| ss; SS;SSE soapsuds (enema) |
| s s onehalf (not acceptable) |
| ST speech therapist |
| Staph staphyloccus |
| STD sexually transmitted disease; short term disability |
| stat statim (immediately) |
| Strep streptococcus |
| Subq subcutaneous |
| supp suppository |
| susp suspension |
| Sz seizure |
| T, temp temperature; time |
| T max maximum temperature |
| tab tablet |
| TAC temporal artery catheter |
| tachy tachycardia |
| TAH total abdominal hysterectomy |
| TB tuberculosis |
| TBSA total burn surface area |
| TBLC term birth, living child |
| TBW total body water |
| T&C type and crossmatch |
| TF tube feeding |
| THR total hip replacement |
| TIA transient ischemic attack |
| tid three times a day |
| TO telephone order |
| top topically |
| tol tolerate, tolerated, tolerance |
| TPN total parenteral nutrition |
| TURP transurethral resection of prostate |
| TWE tap water enema |
| Tx treatment |
| u unit (unacceptable abbreviation) |
| UAC umbilical artery catheter |
| UAO upper airway obstruction |
| unk unknown |
| UOP urinary output |
| up ad lib up (out of bed) as disired (adlibitum) |
| UR upper respiratory; utilization review |
| URI upper respiratory infection |
| Urol urology; urologist |
| US U/S ultrasound |
| USP United States Pharmacopeia |
| UTI urinary tract infection |
| V ventricular; volume |
| VH vaginal hysterectomy |
| V/D vomiting and diarrhea |
| Vent ventral; ventricular; ventilator |
| viz that is, namely |
| VLBW very low birth weight |
| VO verbal order |
| VO2 oxygen consumption |
| vol volume |
| VP venous pressure |
| VRSA vancomycin resistant staph aureus |
| VS vital signs |
| W white; widowed |
| WB weight bearing |
| WBN well baby nursery |
| WC; w/c wheelchair |
| w/d well developed; warm and dry |
| WD well developed |
| WF; wf white female |
| WFL within functional limits |
| WM; wm white male |
| WN;w/n well nourished |
| WNL within normal limits |
| Wt weight |
| W/U;w/u workup |
| X times |
| Xmatch cross match |
| Y year; yes |
| YO; y/o; year(s) old |
| YTD year to date |