Medical Records Abbreviation List



MEDICAL RECORDS ABBREVIATION LIST

a --------------------apical

A assisted

AAROM ---------Active Range of Motion

A2 Second Aortic Sound

aa of each, equal parts

A.A. Alcoholics Annonymous

AAA abdominal aortic aneurysm

AB abortion

abd abdomen

ABD abduction

ABG arterial blood gases

Abn abnormal

ABN---------------advanced beneficiary notice

a.c. before meals (ante cibum)

AC acromioclavicular (Joint)

ACBG aortocoronary bypass graft(ing)

ACLS Advanced Cardiac Life Support

acid phos acid phosphatase

ACTH adrenocorticotropic hormone

A.D. right ear (auris dextra)

ad to, up to

ad. lib as desired

ADA American Diabetes Association

adap equip adaptive equipment

ADC Aid to Dependent Children

ADD adduction

ADH antidiuretic hormone

ADL activities of daily living

Adm admission

AE above-the-elbow (amputation)

AEB----------------as evidenced by

Afeb----------------afebrile

AFB acid fast bacillus

AF atrial fibrillation

Afib----------------atrial fibrillation

AFO Ankle-foot Orthosis

A/G ratio albumin/globulin ratio

AGA approprite for gestational age

AgN03 silver nitrate

AHA American Hospital Association

AHN assistant head nurse

AICD--------automatic inplanted cardioverter defibrillator

AIDS acquired immune deficiency syndrome

AJ ankle jerk

AKA above-the-knee (amputation)

A-line arterial line

alb albumin

alk. phos alkaline phosphatase

ALL Acute Lymphocytic Leuke

ALS ---------------amyotrophic laterial sclerosis

ALT alanine aminotransferase

A.M. morning

AMA against medical advice

amb ambulatory

AMI acute myocardial infarction

AML Acute Myelocytic Leukemia

amp ampule

amt amount

ANA antinuclear antibody

Anes Anesthesia/Anesthesiologist

ant anterior

ante before

A&O alert and oriented

AODM adult onset diabetes mellitus

AORN Association of Operating Room

Nurses

AP ankle pump exercise

A.P. abdominal perineal

A-P anterior-posterior

A&P auscultation & percussion

APPL application

app apparently

approx approximately

A.P.R. abdominal perineal resection

aq water (aqua)

ARDS--------------adult respiratory distress syndrome

ARF acut renal failure

AROM artificial rupture of membranes

A.S. left ear (auris sinistra)

ASA acetylsalicylic acid (aspirin)

ASAP as soon as possible

ASCVD arteriosclerotic cardio-

vascular disease

ASHD arteriosclerotic heart disease

ASD atrial septal defect

ASMI anterosepto myocardial infarction

ASO anti-streptolysin-0

ASIS --------------Anterior/Superior Iliac Spine

assoc associates

asst assistance

AST asparatate amino-transferase

AT Anesthesia Tech

ATA atmospheres absolute

A.T.N.R. asymmetrical tonic neck reflex

A.U. both ears (aures unitas)

AV atrioventricular

Avg. ---------------average

AVR aortic valve replacement

A&W alive and well

ax axillary

Ba.E. barium enema

baso basophil

BBB bundle branch block

BC Blue Cross

BE below-the-elbow (amputation)

BEE basal energy expenditure

BGM blood glucose moitoring

b.i.d. two times a day

bilat bilateral

bili bilirubin

BJP Bence Jones protein

BK breakfast

BKA below-the-knee (amputation)

Bld-----------------blood

bl. cult blood culture

-bld blend or blenderized

BLE both lower extremities

BM bowel movement

BMR basal metabolic rate

BMP --------------basic metabolic profile

BOS base of support

B.O.W. bag of waters

BP blood pressure

BPH benign prostatic hypertrophy

br brown

BR bedrest

BR c BRP bedrest with bathroom

privileges

BRP bathroom previleges

bs bowel sounds

BS blood sugar

B/S breath sounds

BSAS bedside activity sheet

BSC bedside commode

BSE breast self exam

B.S.H.D. beauty shop, hair do

BSO bilateral salphingo-oophorectomy

BSP Bromulphalein

(liver function study)

BTL bilateral tubal ligation

BUE both upper extremities

BUN blood urea nitrogen

B.U.S. Bartholin urethral and

Skene's glands

Bx biopsy

c with

C Centigrade

C-1 to C-7 cervical vertebrae

Ca++ calcium

Ca cancer

CA-----------------clerical associate

C&A Clinitest and Acetest

CABG coronary artery bypass graft(ing)

C-Collar ----------cervical collar

CAD coronary artery disease

cap capsule

Cap Refill --------capillary refill

CAT computerized axial tomography

cat catelog

cath catheter

CBC complete blood count

CBG capillary blood gases

CBI continuous bladder irrigation

CBR complete bed rest

CCMS clean catch midstream

CCT Critical Care Tech

CCU coronary care unit

CD common duct

CEA carcino embryonic antigen

C3H6 cyclopropane

CF Cystic Fibrosis

CG contact guard

CGA clinical gestational age

CH50 total complement

CHD congenital heart disease

CHI ---------------Closed Head Injury

chemo chemotherapy

Chem l2 Chemistry Profile

Chem 20 Chemistry Profile

CHF congestive heart failure

chg change

CHO carbohydrate

Chol cholesterol

Chr chronic

cir circulator

CI cardiac index

circ circumcision

CK creatinine phosphokinase

ck- check

Cl chloride

cl clear

CLL Chronic Lymphocytic Leukemia

clp clamped

Cl Red closed reduction

cm centimeter

CM----------------Case Manager

CMA cardiac monitored ambulation

CME cardiac monitored exercise

CML Chronic Myelocytic Leukemia

CMV controlled mandatory ventilation

CAN---------------certified nurse assistant

CNS central nervous system

CO carbon monoxide

C.O. cardiac output

c/o complained of

CO2 carbon dioxide

coag coagulation

C.O.D. clamp off, dry

COG center of gravity

C.O.L.D. chronic obstructive lung disease

Comm comminuted

comp compound

cond condition

cont continuous

contr contraction

conv convalescent

coordtn coordination

COPD chronic obstructive pulmonary disease

COR heart

Corr ---------------Correct

C.O.T.E. Comprehensive Occupational

SCALE Therapy Evaluation Scale

-cp -----------------chest pain

CP cerebral palsy

C.P. collaborative problem

CPAP continuous positive airway

pressure

C.P.D. cephalopelvic disproportion

CPFT----------Certified Pulmonary Function Technologist

CPJJ carpuject

CPM continuous passive motion

CPR cardiopulmonary resuscitation

CPT----------------chest physiotherapy

CR------------------cardiac rehabilitation

CRICO ------------Cricothyroidomy

CRT-------------- Certified Respiratory Therapist

CRF----------------Chronic renal failure

CS cesarean section

C.S. Contract Services

C&S culture and sensivity

CSF cerebrospinal fluid

CST Certified Surgical Technologist

CT computerized tomography

C&T cervical and thoracic (spine)

C.T. chest tubes

Cult----------------Culture

CV cardiovascular

CVA cerebrovascular accident

CVC consonant vowel consonant

CVCC-------------Cardiovascular Care Center

CVD cardiovascular disease

CVP central venous pressure

CVS cardiovascular system

CW crutch walking

Cx cervix

cx circumflex (Coronary Artery)

CXR Chest X-Ray

cyclo cycloprophane

cysto cystoscopy

Cyt-----------------Cytology

d day

D diastolic

D dependent

D-1 to D-12 Dorsal vertebra 1-12

D.A.T. diet as tolerated

DB drainage bag

DBP diastolic blood pressure

DC discontinue

D/C-----------------discharge

D&C dilatation & curretage

deca ten

deci a tenth

deg degeneration

DF dorsi-flexion

defib----------------defibrillator

DH Deaconess Hospital

DHC---------------Deaconess Home Care

DHL---------------Diffuse histiocytic lymphoma

dia diameter

Diab diabetic

diag diagnosis

Diag Diagonal (coronary artery)

dias diastolic

diff differential

dil dilute

DIP distal interphalangeal

disch discharge

disp dispense

dist distend, distention

dk dark

DJD ---------------Degenerative Joint Disease

DKA Diabetic Ketoacidosis

D5/LR 5% dextrose in water with

lactated ringers

D5/NS 5% dextrose in water with

normal saline

D5/0.2%NaC1--- 5% dextrose in water with

0.2 sodium chloride

D5/0.45%NaC1---5% dextrose in water with

0.45 sodium chloride

DME---------------durable medical equipment

DNA deoxyribonucleic acid

DNR---------------Do not resuscitate

DOA dead on arrival

DOB date of birth

DOE dyspnea on exertion

DOPA dihydroxyphenylalanine

D.P.----------------Discharge Planning

DPL ---------------Diagnostic Peritoneal Lavage

d.p.p. dorsalis pedis pulse

DPNS--------deep pharyngeal neuromuscular stimulation

DPT Diphtheria, Pertussis, Tetanus

Dr doctor

dr dram

DR delivery room

DRG diagnosis related group

drng drainage

drsg dressing

D/S Destrose in Saline

DSA digital subtraction angiogram

DSD dry sterile dressing

dt due to

DT delerium tremens

D/T date/time

DTR deep tendon reflex

DTV due to void

DUB dysfunctional uterine bleeding

DVI digital vascular imaging

DVT deep vein thrombosis

D.W. distilled water

D/W dextrose in water

D5W 5% dextrose in water

D10W 10% dextrose in water

D20W 20% dextrose in water

DWDL------------Diffuse Well Differentiated

Lymphocytic Lymphoma

Dx diagnosis

E Escherichia

e enema

ea each

EBL estimated blood loss

ECCE extra capsular cataract

extraction

ECG, EKG electrocardiogram

echo echocardiogram

ECT electroconvulsive therapy

ED -----------------Emergency Department

EDTU--------------Emergency Department Treatment Unit

EDC estimated date of confinement

EEG electroencephalogram

EENT eye, ear, nose, throat

EF ejection fraction

EFFS External Fixation Foot Support

EFM external fetal monitor

EGD esophagogastroduodenoscopy

elix elixir

EMG electromyogram

enc encourage

Enf Enfamile

Enf c Fe Enfamile with iron

ENT ear, nose, throat

EOB ---------------edge of bed

EOM extraocular movements

EOS eosinophil

EP------------------Electrophysiology

Epis episiotomy

ER Emergency Room

ERCP Endoscopic Retrograde

cholangiopancreatogram

ESR erythrocyte sedimentation rate

E-Stim electrical stimulation

ESRD end stage renal disease

EST electroshock therapy

ESWL Extracoporeal Shockwave Lithotripsy

E.T. Enterostomal Therapist

et and

ETT endotracheal tube

et al and other

ETCO2 -----------End Tidal CO2

ETOH ethyl alcohol

eval evaluation

ex extract

exer exercise

exp expired

exp lap exploratory laparotomy

ext external

ext. rot external rotation

F Fahrenheit

f female

FA fluorescent antibody

FAT ---------------Functional Activity Assessment

FB foreign body

FBS fasting blood sugar

F/C foley catheter

FCE functional capacity evaluation

fdg feeding(s)

FE iron

FECG fetal electrocardiogram

fem femerol

FeS04 Ferrous Sulfate

FF force fluids

FF@U fundus firm at (two or three

or four) finger breadths below

the umbilicus

FH family history

FHP Functional Health Pattern

FHR fetal heart rate

FHT fetal heart tone

fld fluid

flex flexion

FM fetal movement

FMC fine motor control

fn functioning

FNAB fine needle aspiration biopsy

fob foot of bed

FOB father of baby

font fontanel

Fr French

freq frequent

FROM full range of motion

frt fruit(s)

fs flowsheet

FS frozen section

FSE fetal scalp electrode

FSH follicle stimulating hormone

FTA fluorescent treponemal antibody

FTA-ABS fluorescent treponemal antibody

absorption test

FTI free thyroxine index

FTSG full thickenss skin graft

FTT ---------------failure to thrive

5FU fluorouracil

FUO fever of undetermined origin

FWB full weight bearing

Fx fracture

g gram

G gauge

GA General Anesthesia

gastroc gastrocnemius

gav gavage

GB gallbladder

GC gonorrhea (gonococcus)

GCS --------------Glasgow Coma Score

genit genitalia

GGT Gamma Glutamyl Transpeptidase

GH growth hormone

GHJ ---------------Glenohumeral Joint

GI gastrointestinal

Gluc glucose meter

gm gram

GMC gross motor control

GNS----------------Graduate Nurse Specialist

G6PD glucose-6-phosphate

dehydrogenase

gr grain

grav gravity

Grav gravida

Grd, grd ground

G/S glucose in saline

GS glut set exercise

GSW gunshot wound

gt gait

GT gastrostomy

gth girth

gtt drop(s)

GTT glucose tolerance test

GU genitourinary

G/W glucose in water

Gyn gynecology

h hour

HA headache

HAF hyperalimentation fluid

Hamst hamstring exercise

H20 water

H202 Hydrogen Peroxide

HBsAg hepatitis associated antigen

(hp, BAG, Au)

HBO hyperbaric oxygen (therapy)

HBP high blood pressure

HC head circumference

HCG human chorionic gonadotropin

HC1 hydrochloride

Hct hematocrit

HCVD hypertensive cardiovascular disease

HD-----------------Hodgkin's Disease

HDL high density lipoprotein

Cholesterol--------cholesterol

HEENT head, eyes, ears, nose, throat

HEME ------------blood

Hemi --------------hemiparesis

HEP home exercise program

Hg mercury

Hgb hemoglobin

HHA hand held assist

HHC Home Health Care

HHN---------------Hand Held nebulizer

HHNK Hyperosmolar Hyperglycemic

Nonketotic Coma

HI ------------------head injury

HIV human immunodeficiency virus

HIVD herniated intervertebral disc

H.L. heparin lock

HN2 nitrogen mustard

H.O. handout

HOB head of bed

HOH hard of hearing

Hol Hollister

HP Hydrocollator packs

H&P history & physical

HPI history of present illness

hpk hot pack

HR Heart Rate

hr hour

h.s. hour of sleep, bedtime

HS heel slide exercise

ht height

HTLV III human T-cell leukemia/lymphoma

virus (re: AIDS)

HTN hypertension

HVD hypertensive vascular disease

Hx history

H-WP Hubbard Whirlpool

hypo hypodermic injection

Hyst hysterectomy

Hz -----------------Hertz

I131 radioactive iodine

IABP Intra-Aortic Balloon Pump

IBW ideal body weight

ICA ---------------Internal Carotid Artery

ICCE intracapsular cataract extration

ICF intermediate care facility

ICP intracranial pressure

ICR Inpatient Cardiac Rehabilitation

ICRP Inpatient Cardiac Rehabilitation Program

ICS intercostal space

ICU Intensive Care Unit

ID identification

IDC Interdisciplinary Conference (Rehab)

I&D incision and drainage

i.e. for example

IF intrinsic factor

IgG, IgA, IgM Immunoglobin classes, G, A, M,

defined by W.H.O.

IHSS Idiopathic Hypertrophic

Subaortic Stenosis

IDDM--------------Insulin dependent diabetes mellitus

IM intramuscular

IMV intermittent mandatory ventilation

in inch

inapprop inappropriate

INB intercostal nerve block

Incont incontinent

incor---------------incorrect

ind induction

Ind independent

Inf infection

-inf-----------------inferior

infu-----------------infusion

INH isoniazid

Init initials

Instr----------------instruments

INT intermittent

I&O intake and output

Int. rot internal rotation

invol involuntary

IO------------------Intraosseous

IOL intraocular lens (implant)

I.O.P. intraocular pressure

IPPB intermittent positive pressure breathing

IQ intelligence quotient

irreg irregular

irrig irrigate

ISC intermittent self catheterization

Isol isolation

ITP-----------------Idiopathic Thrombocytopenic purpura

IUD intrauterine device

IUFD intrauterine fetal demise

IUPC intrauterine pressure catheter

I of S---------------intensity of service

IV intravenous

IVP intravenous pyelogram

IVPB intravenous piggyback

IVPF intravenous partial fill

jaun jaundiced

JCAHO Joint Commission on Accreditation

of Healthcare Organizations

J.P. Jackson Pratt

jt. ------------------joint

JVD jugular venous distention

K+ potassium

Hypokalemia, Hyperkalemia (See Last Page, Under

Symbols)

KA King-Armstrong (units)

kcal kilocalorie(s), Calorie(s)

KC1 potassium chloride

KELS -------------Kohlman Evaluation of Living Skills

Kg kilogram

KJ knee jerk

17 KS 17 ketosteriods

KUB kidney, ureter, bladder

KVO keep vein open

L liter

LA left atrium

L&A light and accommodation

LAD left anterior descending

(coronary artery)

L&D labor and delivery

L-1 to L-5 lumbar vertebra 1-5

lab laboratory

lac laceration

lap laparotomy

LAP left atrial pressure

lat lateral

L.A.T. left anterior thigh

lav lavage

lax Laxative

lb. Pound

LB -----------------lower body

LBBB left bundle branch block

LBP low back pain

LBQC large base quadriceps cane

LBW low birth weight

LB-WP loboy whirlpool

LCM left costal margin

L.D. left deltoid

LDH lactic dehydrogenase

LDL low density lipoprotein

Le leather

LE lower extremity

LEP lower extremity prep

LE prep lupus erythematosus preparation

L.E.S.I. Lumer Epidural Steroid Injection

LF low forceps

LFA left forearm

lg large

L.G. left gluteal

LGA large for gestational age

LGI lower gastrointestinal

L-G-L- Lown-Ganong-Levine (syndrome)

LIDC --------------Low Intensity Direct Current

LH luteinizing hormone

liq liquid

LKS liver, kidney, spleen

LLB ---------------long leg brace

LLC ---------------long leg cast

LLE left lower estremity

LLL left lower lobe (lung)

LLOQ lower left outer quadrant

LLQ lower left quadrant

LLT left lateral thigh

LMA left mentoanterior

LML left mediolateral (episiotomy)

LMP last menstrual period

LMT left mentotransverse

LNMP last normal menstrual period

LOA left occiput anterior

loa leave of absence

LOB loss of balance

LOC loss of consciousness

LOP left occiput posterior

LOS length-of-stay

LOT left occiput transverse

LP lumbar puncture

LPM liters per minute

LPN Licensed Practical Nurse

L/S ratio lecithin sphigomyelin ratio

LS lumbosacral

LSA left sacroanterior

LSB left sternal border

LScA left scapuloanterior

LScP left scapuloposterior

LSD lysergic acid diethylamide

LSNB lumber symptomatic nerve block

LSP left sacroposterior

L--------------------left

lt left

Lt light

L.T. leisure therapy

L.T.G. long term goals

LTM --------------long term memory

LUE left upper extremity

LUL left upper lobe (lungs)

LUOQ left upper outer quadrant

LUQ left upper quadrant

LV left ventricle

LVAD-------------left ventricular assist device

LVF left ventricular failure

LVH left ventricular hypertrophy

LVMD-------------left ventricular medical device

LW Lee White (method)

L&W living and well

L/W living and well

LWB light weight bearing

lymphs lymphocytes

lytes electrolytes

M meter

m male

MA mental age

MAC Monitored Anesthesia Care

MAE moves all extremities

MAEW moves all extremities well

Manip & Int manipulation and internal

Fix. fixation

MAP mean arterial pressure

MAR medication administration record

Marg marginal

max maximal

MBS---------------Modified barium swallow

MCA --------------Middle Cerebral Artery

mcg or mcgm microgram

MCH mean corposcular hemoglobin

MCHC mean corpuscular hemoglobin

concentration

MCL midclavicular line

MCV mean corpuscular volume

M.D. doctor of medicine

MD muscular dystrophy

MDS---------------Myelodysplastic syndrome

mec meconium

Med. Rec. medical records

mech mechanical

med medication

Med medium

MED medial

medco medcosonlator

mEq milliequivalent

MET metabolic equivalents

mets metastases

M-F Mother – Father

MFR --------------Myofacial Release

MFAR-------------Medication & fluid administration record

MFH---------------Malignant fibrohistiocytoma

Mg++ magnesium

mg. or mgm. milligram

MH marital history

MHU mental health unit

MI myocardial infarction

MIC Medical Intensive Care

milli one-thousandth

min minimal

misc. miscellaneous

mixt mixture

ML midline

ml milliliter

MM Marshall-Marchetti

(test/operation)

mm millimeter

mmHg--------------Mercury

MMKBS Marshall Marchetti Kranz

Bladder Suspension

MMT manual muscle test

mo month

mod moderate

MOM milk of magnesia

mono mononucleosis

MP metacarpal phalangeal

mr mental retardation

MR may repeat

MRI Magnetic Resonance Imaging

MRMT -----------Minnesota Rate of Manipulation Test

MRSA Methicillin Resistent

Staphlococcus Aureus

MRSE-------------Methicillin Resistent Staphlococcus Epidermis

MS multiple sclerosis

MSE musculo skeletal extremities

msg message

MSL midsternal line

MSTL--------------multiple sleep latency test

M.T. monitor technician

mu micron

MUGA multigated study

MUO--------------metastasis of unknown origin

MVA motor vehicle accident

MVC --------------motor vehicle collision

MVP mitral valve prolapse

MVR mitral valve replacement

MWT--------------maintenance of wakefulness test

N ------------------nasal

Na sodium

Hyponatremia, hypernatremia, (See Last Page, Under

Symbols)

NA Nursing Assistant

N/A not applicable

NaC sodium chloride

NaC1 low salt (200-300 mg NaC1) diet

NAD no acute distress

NB newborn

n.b. note well (nota bene)

NC Nasal Cannula

NCB---------------no code blue

NCNC-------------Normal cytic, normal chromic

NCT nerve conduction test

NDT --------------Neurodevelopmental Treatment

NED---------------No evidence of disease

neg negative

neph nephrostomy

NETT Nasal Endotracheal Tube

neuro neurology

NG nasogastric

NGT nasogastric tube

N.H.---------------Nursing Home

NHL-DH----------NonHodgkin's lymphoma,

diffuse hystiocytic

NKA no known allergies

NL--------------------Normal limits

NM neuromuscular

no number

N02 nitrous oxide

noc night

NOS not otherwise specified

NP no problem

NPDL-------------Nodular poorly diffuse lymphoma

NPN non-protein nitrogen

NPO nothing by mouth

NRB --------------Non Re-Breather

NROM normal range of motion

NSAID -----------Non-steroidal Anti-inflammatory Drugs

NS neurological vital signs

N.S. normal saline

NSCLC------------Non small cell lung cancer

NSO Nursing Service Office

Nsg nursing

Nsg Dx nursing diagnosis

NSR normal sinus rhythm

NSS Nutritional Support Service

NST non-stress test

NTG nitroglycerin

nutr nutrition

NTT --------------Naso Tracheal Tube

NV neurovascular

N&V nausea and vomiting

NWB nonweight bearing

NYD not yet diagnosed

O Oral

o none or no

OA ----------------Osteo-arthritis

02 oxygen

OB obstetrics

OBRR Obstetric Recovery Room

OBS----------------Organic brain syndrome

obst obstruction

O.C. open crib

occas occasional

OCG oral cholecystogram

OCT oxytocin challenge test

o.d. right eye (oculus dexter)

OD overdose

OETT Oral Endotracheal Tube

OG ----------------Orogastric

O.H. open heart

OHCRP Open Heart Cardiac Rehabilitation

Program

Ohio NICU Ohio Neonatal Intensvie Care Unit

o.j. orange juice

OM otitis media

OOB out of bed

oop out on pass

OOSC out of special care

OOT out of tent

O.O.T. out of town

Op operation

OP opening pressure

OPC outpatient clinic

ophth ophthalmic

opp opposition

OPT outpatient

OR Operating Room

ORIF open reduction, intenal fixation

ortho orthopedics

OS left eye (oculus sinister)

OSA----------------obstructive sleep apnea

OT occupational therapy

O.T.----------------One Touch (glucose test)

OTC ---------------Over the Counter

OU each eye (oculus uterque)

oz ounce

P pulse

p after

PA pulmonary artery

P.A. pernicious anemia

P-A posterior-anterior

P&A percussion and auscultation

PA & Lat postero-anterior and lateral

PAC premature auricular contractions

PACU Post Anesthesia Care Unit

PAD pulmonary artery diastolic (pressure)

PALS--------------Pediatric advanced life support

PAM pulmonary artery mean (pressure)

Pa01 arterial P02

Pa02 alveolar P02

PAP Papanicolaou (stain, smear, test)

Para number of pregnancies

PAS pulmonary artery systolic (pressure)

PAT paroxysmal atrial tachycardia

path pathology

PAW pulmonary artery wedge

PAWP pulmonary artery wedge pressure

P-bars parallel bars

PBI protein bound iodine

p.c. after meals (post cibum)

PC physical cues

PCA patient controlled analgesia

P.C.A.--------------Patient Care Associate

PCB para cervical block

PCC Patient Care Coordinator

PCEA--------------Patient Controlled Epidural Analgesia

PCIA---------------Patient Controlled Interscalene Analgesia

PCN penicillin

PC02 partial pressure of carbon dioxide

PCP Patient Care Plan

PCWP pulmonary capillary wedge pressure

PDLST physical daily living skills training

PDR Physician's Desk Reference

P.E. physical examination

Ped pediatrician

Peds pediatrics

PEEP positive end expiratory pressure

PEG pneumoencephalogram

P.E.G.--------------percutaneous endoscopic gastrostomy tube

pent pentothal

PER Patient Education Record

per by, through

peri perineal

PERL pupils, equal, react to light

PERLA pupils equal, react to light and

accommodation

Perm----------------Permanent

PF plantar flexion

pfs parenteral fluid sheet

PFT pulmonary function test

PG pregnant

P(GCS) -----------Paralytics

PH past history

pH hydrogen ion concentration

phcy pharmacy

PHD prudent heart diet

Phy. Asst.----------Physicians Assistant

PI present illnes

PICC Peripherally inserted central catheter

PID pelvic inflammatory disease

PIP proximal interphalangeal (joint)

pit pitocin

PJC premature junctional contraction

PKU phyenylketonuria

PLB ---------------Pursed Lip Breathing

Plt------------------Platelet

p.m. night

PMD Physical Medicine Department

PMH past medical history

PMI point of maximal impulse

PNC premature nodal contraction

PNC Pre Natal Clinic

PND paroxysmal nocturnal dyspnea

PNF ---------------Proprioceptive Neuromuscular Facilitation

PNR---------------Perioperative nursing record

p.o. by mouth (per os)

P.O.D.1 postoperative day one

P02 partial pressure of oxygen

polio poliomyelitis

POPPA physician's orders prior to

patient's arrival

PORP partial ortho replacement prosthesis

pos positive

post posterior

postop postoperative

POT Psychiatric Occupational Therapy

P&P policy and procedure

p.p. postpartum

PP&D Percussion, postural drainage

P.P.D. purified protein derivative

(T.B. Test)

PPN peripheral parenteral nutrition

PPP peripheral pulses present

PPP+P pedal pulse present and palpable

PPP+D pedal pulse present and dopplerable

PR per rectum

PRBC packed red blood cells

PRE progressive resistive exercise

pre-med premedication

pre-op before surgery

prep preparation, prepared

prev previous

primip woman bearing first child

p.r.n. when necessary

pro protein

probs problems

proc procedure

Procto proctology

prod productive

PROM premature rupture of membranes

pron pronation

prud prudent

PT prothrombin time

P/S 2::Polyunsaturated to saturaeted fats

PSG----------------polysomnogram

psi(g) pounds per square inch (gauge)

PSP phenolsulfonphthalein

Pt patient

P.T. physical therapy

PTA Percutaneous Transluminal Angioplasty

P.T.A. prior to admission

PTB patellar tendon bearing prosthesis

PTCA percutaneous transluminal coronary

angioplasty

p.t.p. posterior tibial pulse

PTS patellar tendon supracondular

prosthesis

PTT partial thromboplastin time

PUFA Polyunsaturated (fats) fatty acids

pulm pulmonary

Pulse Ox Pulse Oximeter

pulv powder

pur pureed

PV------------------Polycythemia Vera

PVC premature ventricular contraction

PVFD--------------Paradoxical Vocal Fold Dysfunction

PVR post void residual

PWB partial weight bearing

PZI protamine zinc insulin

q every

q.i.d. 4 times a day

q.h. every hour

q.n.s. quantity not sufficient

q.o.h. every other hour

q.s. quantity sufficient

q.2h. every 2 hours

QS quad set

qt quart

qty------------------quantity

quad quadriceps

R rectal

r right

ra room air

RA right atrium

R.A. rheumatoid arthritis

Rad T Radiation Therapy

R.A.I. radioactive iodine

R.A.I.U. radiactive iodine uptake

RAM --------------Rapid Alternative Motion

R.A.T. right anterior thigh

RBBB right bundle branch block

RBC red blood cell/count

RBP retinal binding protein

RCA right coronary artery

RCCLW routine cardiac catheterization labwork

R.D. Registered Dietitian

R.D.S. respiratory distress syndrome

rec received

REC recovery

ref refused

reg regular

rehab rehabiltation

rep repetitions

res -----------------resident

resp respirations

restr. fld. restricted or limited fluids

RFA right forearm

R.G. right gluteal

Rh Rhesus (factorr)

RHC----------------Respriations have ceased

RHD rheumatic heart disease

RHF right heart failure

RhoGam trade name for anti-Rho in

form of lgG

RISA radioactive iodinated serum

albumin (blood volume)

RLE right lower extremity

RLL right lower lobe (lung)

RLOQ right lower outer quadrant

RLQ right lower quadrant

R.L.T. right lateral thigh

rm room

RMA right mentoanterior

RML right mediolateral (episiotomy)

RMP right mentoposterior

RMS Rehabilitative Medicine Services

RMT right mentotranverse

RN Registered Nurse

R/O rule out

ROA right occipitoanterior

rom rupture of membranes

ROM range of motion

ROP right occipitoposterior

ROS review of systems

ROT right occipitotransverse

RPGN rapidly progressive glomerulonephritis

RPh Registered Pharmacist

RPFT---------------Registered Pulmonary Function Technologist

RPSGT-----------Registered Polysomnographic Technologist

RR Recovery Room

RRE ---------------Regressive Resistive Exercise

RRT----------------Registered Respiratory Therapist

RSA right sacroanterior

RSB right sternal border

RSD ---------------Reflex Sympathetic Dystrophy

RSI ----------------Rapid Sequence Intubation

RSP right sacroposterior

RSR regular sinus rhythm

rt -------------------right

R/T related to

R.T. Respiratory Therapy

RTC --------------Return to Clinic

RTS ---------------Revised Trama Score

RTW return to work

RUE right upper extremity

RUL right upper lobe (lung)

RUOQ right upper outer quadrant

RUQ right upper quadrant

RV right ventricle

R&V---------------repeated and verified

Rx ------------------treatment

RW ----------------rolling walker

s without

S systolic

S of I----------------severity of illness

S-1 to S-5 sacral vertebra 1-5

SA sino-atrial

SAQ short ARC quadriceps exercise

SaO2 --------------Oxygen Saturation

sat saturated

satis satisfactory

SB stillbirth

SBA standby assist

SBE subacute bacterial endocarditis

SBFT Small Bowel Follow-Through

S. Brady sinus bradycardia

SBP systolic blood pressure

SBQC small base quadriceps cane

S/C stroke chair

SCC----------------squamous cell carcinoma

SCI ----------------Spinal Cord Injury

SCLC--------------small cell lung cancer

SCN Special Care Nursery

SDS Same Day Surgery

sec second

sed. rate. sedimentation rate

SEMI subendocardial myocardial infarction

Ser------------------serial

serosang serosanguineous

SF salt free

SGA small for gestational age

SGB Stellate Ganglion Block

S(GCS) -----------Swollen

SGOT serum glutamic oxalic

transaminase

SGPT serum glutamic pyruvic

transaminase

SIC Surgical Intensive Care

SIMV-----synchronized intermittent manditory ventilation

sl slight

SL sublinsual

SLB ---------------Short Leg Brace

SLC ---------------Short Leg Cast

SLE systemic lupus erythematosis

SLR straight leg raising

sm small

SMA-12 (-20) chemistry profile

SMR submucous resection

SN Student Nurse

SNF skilled nursing facility

s04 sulfate

S/O significant other

SOAP subjective, objective, assessment,

plain

SOB short of breath

Soc. Hx. social history

Soc. Serv. Social Service

sol solution

Sp -----------------spontaneous

spec specimen

S/P status post

S.P. suprapubic

sp. gr. specific gravity

spont. spontaneous

S-P-S stand-pivot-sit transfer

SPT supracondylar patellar

tendon prosthesis

spt spirit

SQ subcutaneous

sr siderails

SR sinus rhythm

SROM spontaneous rupture of membranes

ss one-half

SS soap suds

s/s signs and symptoms

SSE soad suds enema

SSKI saturated solution of potassium iodide

ST speech therapy

STD ---------------Sexually Transmitted Disease

STM --------------Short Term Memory

S. Tach sinus tachycardia

staph staphylococcus

Stat at once

STG short term goal

str straight

strep streptococcus

sup supination

supp suppository

Surg----------------Surgery

SVCS--------------Superior Vena Cava Syndrome

Sv02 mixed venous oxygen saturation

SVR systemic vascular resistance

SVT supraventricular tachycardia

Sx signs, symptoms

SW ----------------Stab Wound

S.W.----------------Social Work

S.Y.H.A.B. Since You've Had a Baby (Book)

Sys-----------------Systolic

t trace

T temperature

T-1 to T-12 thoracic vertebrae 1 - 12

T3RIA triiodothyronine

T3U triiodothyronine resin uptake

T4 thyroxine

T7 free thyroid index

T&A tonsillectomy & adenoidectomy

tab tablet

TAH & BSO total abdominal hysterectomy

& bilateral salpingo-oophorectomy

TAT turnaround time

TB tuberculsosis

TBI ---------------Traumatic Brain Injury

TBLC ------------term birth, living child

tbsp tablespoon

TCA therapeutic community assignment

TCC----------------Transitional Cell Carcinoma

TCDB turn, cough, and deep breath

T&C type and crossmatch

TCOM transcutaneous oxygen monitor

TcPC02 transcutaneous PC02 measurement

TcP02 transcutaneous P02 measurement

TDWB -----------Touch Down Weight Bearing

TEDS elastic stockings

tend tenderness

TENS Transcutaneous Electrical Nerve

Stimulation

tet tetanus

TF tube feeding

T/G triglycerides

T(GCS) -----------Tubed

THR target heart rate

THRA total hip replacement arthroplasty

TIA transient ischemic attack

TIBC total iron binding capacity

t.i.d. three times a day

tinct tincture

TKE terminal knee extension

TKRA total knee replacement arthroplasty

TLC total lymphocyte count

TLFS Teaching Learning Flowsheet

TLR tonic labrinthine reflex

T.M. tympanic membrane

TMA -------------Transmetataral Amputation

TMJ temporal mandibular joint

TNM takes no medicine

TNR tonic neck reflex

t.o. telephone order

TOG Task Oriented Group

tol tolerate

top topical

tox toxoid

TP total protein

TPA ---------------tissue plasminogen activator

TPN total parenteral nutrition

TPR temperature, pulse and respiration

tr trace

trig triglyerides

T&S type and screen

TSH thyroid stimulating hormone

tsp teaspoon

TT tilt table

TTWB toe touch weight bearing

TURP transurethral resection of prostate

TW tap water

TWE tap water enema

Tx treatment

TX-----------------transferred

tx traction

Type I, II, II,

IV, or V hyperlipoproteinemia

I, Ii, III, IV, V

UA urinalysis

UBW usual body weight

UCG pregnancy test (urine test)

UE upper extremity

UGI upper gastrointestinal

UB ----------------upper body

UL upper lobe

ung ointment

uni one

U/O unable to obtain

UOA United Ostomy Association

UPF ureteropulvic junction

URI upper respiratory infection

UROL urological

US ultrasound

U.S. Unit Secretary

US/ES ultrasound combined with

electrical stimulation

USD ultrasound diagnosis

USP United States Pharmacopeia

UT Urological Technician

UTI urinary tract infeciton

UUN urinary urea nitrogen

UV ultra violet

UVJ ureteral vesical juncion

v volts

VA Veterans Administration

VAD venous access device

vag vaginal

Vasc-----------------Vascular

VC vital capacity

VCG vectocardiogram

VD veneral disease

vdg voiding

VDRL veneral disease research lab

VE vaginal exam

veg vegetable

VER ---------------Visual Evoked Response

v.f. -----------------Visual Field

V Fib ventricular fibrillation

vit vitamin

VMA vanylmandelic acid

VNA Visiting Nursing Association

v.o. verbal order

vol volume

V pad vaginal pad

VRE----------------Vancomycin Resistant Enterococcus

VS vital signs

VSD ventricular septal defect

VSRP -------------velocity spectrum rehabilitation program

VSS vital signs stable

VT ventricular tachycardia

VUC Voiding Uretheral Cystogram

WB weight bearing

WBAT weight bearing as tolerated

WBC while blood count/cell

WC wheelchair

W/D warm and dry

WD well developed

WFL within functional limits

WIC Women, Infant, Children Program

wk week

wknd weekend

wkr walker

WN well nourished

WNL within normal limits

wp whirlpool

WP wedge pressure

WPW Wolff-Parkinson-White (syndrome)

W/S------------------Watt seconds

wt weight

WT watts

x times

X----------------------across

x-match crossmatch

yel yellow

y/o year old

yr year

SYMBOLS

@ at

v systolic blood pressure

diastolic blood pressure

# number, weight

' foot

" inch

ii two

/ per

: ratio

+ positive

- negative

= equal

( does not equal

> greater than

< less than

% percent

ounce

♀ female

♂ male

increase

decrease

and

degree

~ similar

ø no (i.e. visual change)

change

negative

1/2 one-half

// parallel

* further documentation

heart

one

three

... etc.

( ---------------------------- checked and completed

K -------------- hypokalemia

K --------------- hyperkalemia

Na ------------- hyponatremia

Na -------------- hypernatremia

----------------- one

----------------- two

------------------ three

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