MEDICAL ABBREVIATIONS - Know These! Proper use of medical abbreviations greatly increases a Scribe’s efficiency. If the Scribe can use an approved abbreviation to decrease the amount of time documenting the history or the exam, then it should be done. This will not only increase the Scribe’s productivity, but will also provide more time to observe the physician, document labs and X-rays, etc. Remember to restrict or eliminate abbreviations in the “Orders” and “Diagnosis” sections of the Medical Record. Abbreviations may not be used in the Discharge section of a chart. AFib Atrial Fibrillation BSG Blood Sugar Glucose AAA Abdominal aortic aneurysm BUE Bilateral upper extremities AB Abortion CABG Coronary Arterial Bypass abd Abdomen, Abdominal ABG Arterial Blood Gas CAD Coronary Artery Disease abx Antibiotic cath Catheter, catheterization AMA Against Medical Advice CBC Complete Blood Count AMI Acute Myocardial Infarction CHF Congestive Heart Failure AMS Altered mental status CHI Closed Head Injury approx Approximately chole Cholecystectomy appt Appointment CMT Cervical Motion Tenderness appy Appendectomy CNS Central Nervous System ASA Acetylsalicylic Acid c/o Complains of (Aspirin) CO2 Carbon Dioxide Auto/Ped automobile vs. pedestrian COPD Chronic Obstructive A&O x3 Alert & Oriented x3 (person, Graft Pulmonary Disease place, time) CP Chest Pain BBS Bilateral Breath Sounds CPAP Continuous Positive Airway BCP Birth Control Pill bilat Bilateral BLE Bilateral lower extremities BM Bowel movement C&S Culture & Sensitivity BP Blood Pressure CSF Cerebrospinal Fluid BS Bowel sounds, breath sounds Pressure CPR Cardiopulmonary Resuscitation © 2012 PhysAssist Scribes, Inc. 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CONFIDENTIAL -­‐ NOT FOR EXTERNAL USE 1 CTA Clear to Auscultation, CT Fx Fracture Angiogram F/U Follow Up CV Cardiovascular GB Gallbladder CVA Cerebrovascular Accident GCS Glasgow coma scale CVAT Costovertebral angle GERD Gastro esophageal reflux tenderness disease CXR Chest X-Ray GSW Gunshot wound C-Collar Cervical collar HA Headache C-Spine Cervical spine Hgb Hemoglobin C-Section Cesarean section HCT Hematocrit d/c Discontinue HTN Hypertension DIP Distal Interphalangeal (joint) h/o History of DJD Degenerative Joint Disease HR Heart rate DKA Diabetic Ketoacidosis Hx History DM Diabetes mellitus Hyst Hysterectomy DNR Do not resuscitate IBS Irritable bowel syndrome DTR Deep tendon reflex ICD Implantable cardioverter- DVT Deep vein thrombosis Dx, dx Diagnosis ICE Ice, compression, elevation EKG (ECG) Electrocardiogram ICH Intracranial hemorrhage EOMI Extra ocular movements ICP Intracranial pressure intact IM Intramuscular epi Epinephrine IUP Intrauterine pregnancy EtOH Ethyl Alcohol (consumption, IV Intravenous dependency) IVPB Intravenous piggyback ETT Endotracheal Tube I&D Incision and Drainage FB Foreign body JVD Jugular venous distension FHT Fetal heart tone KUB Kidneys, ureters, bladder (X- FROM Full Range of Motion FTN Finger-to-nose (coordination L Left test) lac Laceration defibrillator ray) © 2012 PhysAssist Scribes, Inc. 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CONFIDENTIAL -­‐ NOT FOR EXTERNAL USE 2 LBBB Left bundle branch block NVID NeuroVascularly Intact LFT Liver function test LLQ Left Lower Quadrant NS Normal Saline LMP Last Menstrual Period O2 Oxygen LNMP Last Normal Menstrual obs Observe Period OD Overdose LOC Loss of Consciousness Ortho Orthopedic; orthopedics LP Lumbar Puncture PA & Lat Posteroanterior and lateral (x- L-spine Lumbar spine LUQ Left Upper Quadrant palp Palpation LVH Left Ventricular Hypertrophy PCN Penicillin MAEW Moves all extremities well PCP Primary Care Physician med, meds Medication; Medications PE Pulmonary embolism MI Myocardial Infarction PERRLA Pupils equal, round and MIP Metacarpointerphalangeal reactive to light and (joint) accommodation Distally rays) MVC Motor Vehicle Collision PID Pelvic Inflammatory Disease NAD No Acute Distress PIP Proximal interphalangeal NCAT Normocephalic, atraumatic NG Nasogastric post-op Post operative NH Nursing Home PPD Packs per day (cigarettes) NKA No known allergies preg Pregnancy, pregnant NKDA No known drug allergies PRN As needed nl Normal Pt Patient NPO Nothing per os (by mouth) PTA Prior to Arrival NRB Nonrebreather (oxygen mask) PTX Pneumothorax NSR Normal Sinus Rhythm PUD Peptic Ulcer Disease NTG Nitroglycerin PVC Premature ventricular N/V Nausea and vomiting N/V/D Nausea, Vomiting, Diarrhea (joint) contractions PVD Peripheral Vascular Disease q Each, Every © 2012 PhysAssist Scribes, Inc. All rights reserved. CONFIDENTIAL -­‐ NOT FOR EXTERNAL USE 3 q.d. Every day STAT, stat At once, immediately q.h. Every hour STD Sexually transmitted disease q.h.s. At Bedtime, every night strep Streptococcus R Right SVT Supraventricular tachycardia RA Room Air Sx Symptoms RA Rheumatoid Arthritis tachy Tachycardia RBBB Right Bundle Branch Block TIA Transient Ischemic Attack RBC Red blood cells TM Tympanic Membrane resp Respiration, respiratory trach Tracheotomy, tracheostomy RICE Rest, ice, compression, T-spine Thoracic spine elevation TTP Tender to palpation RLQ Right Lower Quadrant Tx Treatment R/O Rule out UA Urinalysis ROM Range of Motion UDS Urine Drug Screen RR Respiratory rate URI Upper Respiratory Infection RRR Regular rate and rhythm US Ultrasound RUQ Right Upper Quadrant (of UTD Up to date Abdomen) UTI Urinary Tract Infection Rx Prescription V-Fib Ventricular fibrillation SBO Small bowel obstruction VS Vital Signs scope Arthroscopy, Endoscopy VSS Vital Signs Stable script Prescription V-Tach Ventricular tachycardia SEM Systolic Ejection Murmur WBC White Blood Count SI Sacroiliac (joint) W/D Warm and Dry SLR Straight-leg raise WDWN Well-developed, well- SOB Shortness of Breath sono Sonogram WNL Within Normal Limits s/p Status Post YTD Year to date SP Suprapubic SR Sinus Rhythm nourished © 2012 PhysAssist Scribes, Inc. 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