SUBJECT:ABBREVIATIONS
The following abbreviations cannot be used due to conflict, confusion, and or easily mistaken for another abbreviation:
ABBREVIATION / POTENTIAL PROBLEM / PREFERRED TERMU (for unit) / mistaken as zero, four, or cc / write 'unit'
IU (for internal unit) / mistaken as IV or 10 / write 'internal unit'
Q.D. (for once daily)
Q.O.D. (for every other day) / mistaken for each other; letters and periods after each letter may be mistaken for letters / write 'daily' or 'every other day'
Trailing zero (X.0 mg)
Lack of leading zero (.X mg) / decimal point is misplaced / never write a zero by itself after a decimal point, and always use a zero before a decimal point
MS
MSO4
MgSO4 / confused for one another; can mean morphine sulfate or magnesium sulfate / write 'morphine sulfate' or 'magnesium sulfate'
Abbreviations used by the Center staffs that have been sanctioned for general use on the patient record are as follows:
@At
AbdAbdomen
acBefore meals
AC IOLAnterior chamber intraocular lens
ad libAt discretion, as needed
admAdmitted
AFBAcid fast bacilli
AK ampAbove knee amputation
ambAmbulate
ampAmpule
A.M.Morning
AMAAgainst medical advice
amtAmount
APAnterior posterior
approxApproximate
ASAAcetylsalicylic acid (aspirin)
ASCVDArteriosclerotic cerebrovascular disease
A-VArteriovenous
AXAxillary
BBBBundle branch block
BCPBirth Control Pills
Bil, bilatBilateral
BEBarium enema
Bid Twice a day
BMBowel movement
BMRBasal metabolism rate
BMTBilateral Myringotomy with tube insertion
B/P,BPBlood Pressure
BPHBenign prostatic hypertrophy
BUNBlood urea nitrogen
ScWith
CCentigrade
CACarcinoma
CapCapsule
CathCatheter
CBCComplete blood count
CCChief complaint
certCertification
CHFCongestive heart failure
CHDCoronary heart disease
cmCentimeter
CNACertified Nurse Aide
CNSCentral nervous system
CO2Carbon dioxide
CompCompound
COPDChronic obstructive pulmonary disease
C & SCulture and sensitivity
CPRCardiopulmonary resuscitation
CRNACertified Registered Nurse Anesthetist
CVACerebrovascular accident
D&CDilation and curettage
dxDiagnosis
dischDischarge
DMDiabetes mellitus
DOADead on arrival
DOBDate of birth
DrDoctor
DTDelirium tremens
DTRDeep tendon reflexes
ECGElectrocardiogram (graph)
EEGElectroencephalogram
EENTEye, ear, nose and throat
e.g.For example
EKGElectrocardiogram
EMGElectromyogram
ENTEar, nose, throat
E, coliEscherichia coli
elixElixir
EREmergency Room
ESRErythrocyte sedimentation rate
ETEndotracheal tube
examExamination
expExpired
extExternal
FFahrenheit
FBForeign body
FBSFasting blood sugar
FeIron
FlFluid
FUOFever of undetermined origin
FxFracture
GBGallbladder
GIGastrointestinal
gmGram
grGrain
GttsDrops
GPGeneral Practice
GUGenitourinary
GynGynecology
hrHour
H2O Water
Ht, HctHematocrit
Hb, HgbHemoglobin
HCVDHypertensive cardiovascular disease
H & P History and physical
HtHeight
HxHistory
ICCEIntracapsular cataract extraction
I & DIncision and drainage
IMIntramuscular
impImpression
IOLIntraocular lens
I & OIntake and output
IrregIrregular
IVPIntravenous pyelogram
IVIntravenous
KPotassium
KgKilogram
KCLPotassium chloride
KUBKidney, ureter, bladder
LLeft
labLaboratory
latLateral
L1, L2, etc.Lumbar vertebra
lbPound
LBBBLeft bundle branch block
Liq Liquid
LLELeft lower extremity
LLLLeft lower lid or lobe
LLQLeft lower quadrant
LMPLast menstrual period
LOALeave of absence
LPLumbar puncture
LPNLicensed Practical Nurse
LQLower quadrant
LRQLower right quadrant
LSLumbarsacral
LULLeft upper lobe
LUQLeft upper quadrant
LVHLeft ventricular hypertrophy
LVNLicensed Vocational Nurse
MACMonitored Anesthesia Care
medMedication
Meq, meqMilliequivalent
Mgm, mgmMilligram
MIMyocardial infarction
minMinute
mlMilliliters
mmMillimeters
modModerate
MRMedical Record
NaSodium
NA, N/ANonapplicable
negNegative
neuroNeurology
nilNothing
NKANo known allergies
NPONothing by mouth
N/S, NSNormal saline
NSRNormal sinus rhythm
N & VNausea and vomiting
OmtOintment
OOBOut of bed
OphthOphthalmology
OROperating Room
OrthoOrthopedic
OTOccupational Therapy
oz Ounce
O2Oxygen
OpOperative
/pAfter
PPulse
papPapanicolaou
PathPathology
pcAfter meals
PCPosterior
PCNPenicillin
PEPhysical examination
PERRLA Pupils, equal, regular, react to light and accommodation
PIPresent illness
PIDPelvic inflammatory disease
PMEvening
PO, poBy mouth
prepPreparation
prnAs often as necessary
pro timeProthrombin time
ptPatient
PTTPartial Thromboplastin Time
P.T.Physical Therapy
PVCPremature ventricular contraction
PVDPeripheral vascular disease
qEvery
qhEvery hour
qid Four times a day
qnEvery night
qnsQuantity not sufficient
qsQuantity sufficient
qtQuart
q2hEvery 2 hours
q3hEvery 3 hours
RRespiration
RACResponsible adult companion
RBBBRight Bundle Branch Block
RBCRed blood count
RegRegular
RhRhesus blood factor
RLERight lower extremity
RLLRight lower lobe
RLQRight lower quadrant
RMLRight middle lobe
RNRegistered Nurse
R/ORule out
ROSReview of systems
RULRight upper lobe
RUQRight upper quadrant
RxMedication
SsWithout
satSaturated
SGOTSerum glutamic oxalacetic transaminase
SGPTSerum glutamic pyruvic transaminase
SOBShortness of breath
solSolution
specSpecimen
SSN, SS#Social Security Number
StaphStaphylococcus
statAt once, immediately
strepStreptococcus
Sub lingSublingually
Sub-qSubcutaneous
suppSuppository
surgSurgery
TabTablet
TBTuberculosis
tbspTablespoon
TIATransient ischemic attack
tidThree times a day
tincTincture
TOTelephone order
tspTeaspoon
TURTransurethral resection
TURPTransurethral resection of prostate
TPRTemperature, pulse, respiration
TX, txTreatment
UAUrinalysis
ULQUpper left quadrant
URIUpper respiratory infection
URUtilization Review
USPUnited State Pharmacopeia
UTIUrinary tract infection
VAVisual acuity
vagVaginal
VDVenereal disease
vitVitamin
VOVerbal order
WBCWhite blood count
W/DWell developed
W/NWell nourished
wkWeek
wtWeight
yrYear
SYMBOL
oDegree
Increase or greater than
Decrease or lesser than
F or Female
M or Male
oSecondary
LtLeft
RtRight
=Equal
MED RECORDS 90 AbbreviationsPage 1 of 7