Abbreviation List for Medical Record Documentation



accel A&P A.M. A/G A2 AA aa AAT AB abd ABG Abn ABW AC A-C ACL ad lib ADH ADL adm AFB AFI AFib AFP AGA agit. AgNo3 AIDS AK AKA AKI Alb alb. ALD ALS alt. AMA AMB AMI amnio

ABBREVIATION LIST FOR MEDICAL RECORD DOCUMENTATION

before acceleration anterior & posterior before noon Albumin globulin ratio Aortic Second sound Acute Appendectomy of each, equal parts ambulate as tolerated abortion abdomen arterial blood gases abnormal adjusted body weight Air Contrast Acromio-clavicular Anterior Cruciate Ligament as much as needed, as desired anti-diuretic hormone Activities of daily living admission acid-fast bacilli Amnitotic fluid index atrial fibrillation alpha fetaprotein Appropriate for gestational age shake or stir Silver Nitrate Acquired Immunodeficiency Syndrome above-knee above-knee amputation acute kidney injury Albuterol albumin alcoholic liver disease amyotrophic lateral sclerosis alternate, alternating Against Medical Advice ambulatory Acute Myocardial Infarction amniocentesis

amp amt. AMU ant. ante AODM approx appt Appy aq aq. dest ARDS AROM ASA ASCVD ASD ASHD ASIS asst ASU ATach Aug AV avg AVN AVSS b.i.d. B.O.M. B1 B2 BBB BE BF bil. bili BK BKA Bl. BM BMI BMP

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ampule amount Acute Medical Unit anterior before Adult Onset Diabetes Mellitus approximately appointment appendectomy water distilled water Adult respiratory distress syndrome Artificial rupture of membranes Aspirin Arteriosclerotic cardiovascular disease atrial septal defect arteriosclerotic heart disease anterior superior iliac spine assistance Acute Surgical Unit Atrial Tachycardia Augmentation atriovenous average atrioventricular node afebrile, vital signs stable twice daily bilateral otitis media thiamin Riboflavin Bundle Branch Block barium enema breast feeding bilateral bilirubin below-knee Below knee amputation bleeding Bowel Movement Body Mass Index Basic Metabolic Panel

BMR BOA BOM BOW BP BPH BPP BR brady BRB Brk BRP BS BSA BSC BSE BSER BSN BSO BST BUE BUN BVM BVT Bx

C C&S c&v C.O. C.S.M. c/o C/S C/W CA Ca++ CABG CAD Cal CAN Caps CAT cath CBC

basal metabolic rate born out of asepsis Bilateral Otitis Media Bag of Water blood pressure benign prostatic hypertrophy Biophysical Profile Bathroom bradycardia bright red blood Bronkosol bathroom privileges blood sugar body surface area bedside commode breast self-exam brain stem evoked response Bachelor of Science, Nursing bilateral salpingo-oophorectomy Breast stimulation test bilateral upper extremity blood urea nitrogen bag value mask bag value tube biopsy with centigrade culture and sensitivity cupping & vibration Cardiac output circulation, sensation and motion complaining of Cesarean section consistent with carcinoma, cancer Calcium coronary artery bypass graft coronary artery disease calorie cord around neck capsule Computerized Axial Tomography catheterization complete blood count

CBR CBS CCU CDC CEA cm. CHB CHD CHF chg chol CI circ. cl CL Cl. Liq. Cl. Time cldy cm H20 CMML CMS CNA CNS CO2 cocci comp. conc. conf cong cont. Cont.aero COPD CPAP CPD CPK CPM CPR CPT CRAMS

CRNA CRP CS CSF

complete bed rest chronic brain syndrome Coronary Care Unit Center for Disease Control carcinoembryonic antigen centimeter complete heart block Congenital heart disease Congestive Heart Failure change cholesterol coronary insufficiency circumcision clear chloride clear liquids clotting time cloudy centimeters of water pressure Chronic myelomonocytic leukemia Circulation, motion, and sensation certified nurses aide central nervous system carbon dioxide coccidioidomycosis compound concentrated conference congested continued Continuous Aerosol chronic obstructive pulmonary disease continuous positive airway pressure cephalopelvic disproportion creatinine phosphokinase continuous passive motion cardiopulmonary resuscitation Chest Physiotherapy Circulation, Respiration, Abdomen, Motor, Speech Certified Registered Nurse Anesthetist C-Reactive protein Central Supply cerebrospinal fluid

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CSP CST CT CTA ctx Cu cu. mm. CV CVA CVC CVP CXR CTR D&C D.O.E. D.O.S. D.R. D.T. D.W. d/c-dc D/RL D/W D5LR D5W DAT DBP DDI Decel decr decub defib dept DES dev seq DFA diag diam DIC dil. DIP disch DISH disp div

Central Sterile Processing contraction stimulation test computerized tomography clear to auscultation cervical traction copper cubic millimeter cardiovascular cerebrovascular accident central venous catheter central venous pressure chest x-ray Carpal tunnel release dilatation and curettage dyspnea on exertion Day of surgery Delivery Room delirium tremens distilled water discontinue dextrose and Ringer's Lactate dextrose and water 5 percent dextrose Lactated Ringers 5% dextrose in water diet as tolerated diastolic blood pressure dressing dry & intact decleeration decrease or diminish decubitus defibrillation department Diethylstilbestrol developmental sequences diet for age diagnosis diameter disseminated intravascular coagulopathy dilute or dissolve distal interphalangeal joint discharge Diffuse idiopathic skeletal hyperostosis dispense divide

DJD DKA DLCO DM DME DNR DO DOA DOB DR dr. drng drsg DSD DSE DU DUB DVT DX E. Coli e.g. E.S. EBL ECCE ECG ED EDC EDC EDD EDP EEG EENT eff EFM EGA EGD EKG elix EMG Enf ENG ENT EOA EOM

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Degenerative Joint Disease Diabetic Ketoacidosis Diffusion capacity of lung Diabetes Mellitus Durable medical equipment Do not resuscitate Doctor of Osteopathy Dead on Arrival Date of Birth Doctor dram drainage dressing dry sterile dressing daily skills evaluation duodenal ulcer dysfunctional uterine bleeding Deep Venous Thrombosis Diagnosis Escherichia coli for example electrical stimulation Estimated blood loss Extracapsular Cataract Extraction Electrocardiogram Emergency Department Estimated date of confinement Estimated date of conception end diastolic diameter end diastolic pressure Electroencephalogram Ears, eyes, nose & throat effective external fetal monitor estimated gestational age esophagogastroduodenoscopy Electrocardiogram elixir electromyogram Enfamil electronystagmography Ears, nose & throat esophageal obturator airway extraocular muscles

EPID EPIS Eq Su ERCP

ERV ESD ESR est. ET et. etiol ETOH ETT EUA eval ex exer. Exp. Exp. Lap expl. ext. F F.F. F.F.P. f.o.b. F/U FACH FAS FB FBS FDA fdg fe Fe FH FHM FHR FHT Fi02 fib fl. Fl. dr. fl. oz.

epidural episiotomy equipment set-up endoscopic retrograde cholangiopancreatography expiratory reserve volume end systolic diameter Erythrocyte sedimentation rate estimate Endotracheal and etiology Ethyl alcohol endotracheal tube examination under anesthesia evaluation excision exercise Expired Exploratory laparotomy exploratory external Fahrenheit force fluids fresh frozen plasma foot of bed Follow-up forceps after coming head fetal alcohol syndrome foreign body fasting blood sugar Food & Drug Administration feeding female iron family history fetal heart monitor fetal heart rate fetal heart tones oxygen percentage fibrillation fluid fluid dram fluid ounce

FM FMC FP FPL FRC Freq FSE FSH ft. FTSG FUO FVC FWB fx G/S G/W GA gal gastroc GB GBS GDM GERD GGT G-Hgb GI GLU glut gm gm% GN GPN gr Grav, Gr gt gtt GTT GU GYN H&H H&L H&P H202 H2O HA

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fetal movement Family Maternity Center Family Practice flexor pollicus longus functional residual capacity frequency fetal scalp electrode follicle stimulating hormone foot full-thickness skin graft fever of undetermined origin forced vital capacity full weight bearing fracture glucose and saline glucose and water gestational assessment gallon gastrocnemius gallbladder Group B strep gestational diabetes mellitus gastro esophageal reflux disease gamma glutamyl transferase glycosylated hemoglobin gastrointestinal glucose gluteal gram grams percent graduate nurse graduate practical nurse grain Gravida drop drops Glucose Tolerance Test genitourinary gynecology Hemoglobin & Hematocrit heart and lungs history and physical hydrogen peroxide water headache

HAE HASHD HAT HbA HBIG HBP HbSAb HbSAg HC HCG HCO3 HCVD HDL HEENT HELLP

hemi Hep B Hep L,HL HF HFP Hg Hgb HHD HHN HIDA histo HIV HMD HNP HOB hp HPI HPTN HR hr,h HSP HSV HT Ht. HTN HWP hx hypo

hearing aid evaluation Hypertensive arteriosclerotic heart disease Hemovac Auto Transfuser glycosylated hemoglobin Hepatitis B Immune Globulin High Blood Pressure Hepatitis B surface antibody Hepatitis B surface antigen head circumference human chorionic gonadotropin bicarbonate Hypertensive Cardiovascular disease high density liquid protein head, eyes, ears, nose & throat hemolysis, elevated liver enzymes & low platelet syndrome half Hepatitis B Heparin lock Heparin flush High Fowler's position mercury hemoglobin Hypertensive heart disease hand held nebulizer hepato-iminodiacetic acid histoplasmin Human Immunodeficiency virus Hyaline Membrane Disease herniated nucleus pulposus head of bed hot pack history of present illness hypertension heart rate hour Henoch-Sch?nlein purpura herpes simplex viruses Hubbard Tank height Hypertension home walking program history hypodermically

hyst. I I&D I&O i.e. I.V. I:E IABP IBW IC ICP ICPM ICU id. IDDM IDM IFM IM IMI IMV inc. incr Ind indep inf init inj INR ins insp. instr. int. invol IOL IOP IP IPG IPPB IQ IRV IS iso Isol. Isup

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hysterectomy Iodine incision and drainage intake and output that is intravenous Inspiratory time to Expiratory time ration Intra-aortic Balloon Pump Ideal Body Weight intracardiac intracranial pressure intracranial pressure monitoring Intensive Care Unit the same Insulin-dependent diabetes mellitus infant of diabetic mother internal fetal monitor intramuscular Inferior Myocardial Infarction Intermittent Mandatory Ventilation incontinent increase induction independent infection initials injection International Normalization Ratio insurance inspiratory instructions internal involuntary Intraocular lens intraocular pressure inpatient Impedence Phlebograph intermittent positive pressure breathing intelligence quotient inspiratory reserve volume incentive spirometry isoenzymeisol isolation Isuprel

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