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Each facility will have a list of approved acronyms, abbreviations, and symbols. Please ask to review the list at each facility. An acronym or abbreviations may have more than one meaning: evaluate it in context. Some anonyms, abbreviations and symbols have become unacceptable to use due to their high propensity for error. Some are included in this list (followed by unacceptable abbreviations.) At the end of this list is a table of unacceptable abbreviations that the Joint Committee for Accreditation or Healthcare Facilities requires for all healthcare institutions. Each facility is also supposed to add additional “do not use” acronyms, etc. You may still see some of them in charts (old habits die hard) so you need to know them. In addition, drug names are not to be abbreviated with the exception of ASA, HCTZ, and vitamins. In addition to the abbreviation, you should know the definition of the word or have an idea of the described condition, know metric abbreviations (L, mg, ml, etc.) and know abbreviations of common minerals along with vitamins. Very Important Note: This is a US list. If you are reviewing foreign records, all bets are off. Do NOT make assumptions that acronyms, abbreviations and symbols are the same.
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
X times
Xmatch cross match
Y
YO? y/o year(s) old
YTD year to date