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Approved Medical Abbreviations for Charting
Policy#: ADM 162
APPROVED BY: Anthony Dallas, MD, CMO
ADOPTED:
SUPERCEDES POLICY:
REVISED:
REVIEWED :
12/10/2015
OBJECTIVE:
To create clear and cohesive chart notes.
SCOPE:
All CareHere Health Centers
POLICY:
Care Here has approved the following medical abbreviations for acceptance in the patient EMR. Please lim it use of
yo ur abbreviations to this li st. When using th ese abbreviations, they are to be typed or written as they appear in
this document.
PROCEDURE:
The following is a list of common ly used abbreviation s that are being used in medical documentation. This list is not
all in clusive, or is it intended to in struct users t o apply only th ese abbreviations w hen documenting in the medical
record . Documenting the entire condition, cause, disease, or syndrome is always best practice in medical
documentation.
A
A&O x3
A&Ox4
A-FIB
AAA
AAAAA
ABC
ABO
ACE
ACLS
AD
ADH
ADL
ad li b
AH
AHD
AIDS
AK
AKA
ALS
AMA
AMI
AMT
APPROX
ARC
ARF
AR I
ARDS
alert and orientated to person , place, and time
alert and orienta t ed to person , place, tim e, and event
atri al fibrillation
abdomina l aortic aneurysm
aphasia, agnosia, apraxia, agraphia, alexia
airway, breathing, and circulation
abdomen or abdominal
angiotensin-converting enzyme
advanced card iac life support
admitting diagnosis
antidiuretic hormon e
activities of daily living
as desired
abdom in al hysterectomy
arteriosc lerotic heart disea se
acq ui red immune deficiency synd rome
above the knee
above the knee amputa ti on
advanced life support
against medical advice
ac ute myocardial infarction
Amount
app roxim ate
AIDS-re lated comp le x
acute renal failure
acute res pi ra to ry infect io n
adu lt respiratory distress syndrome I acut e respiratory distress syndrome
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art
arteria l
ASA
ASCVD
aspirin
arteriosclerotic cardiovascular disease
ATLE
apparent life threaten ing event
ATN
A&W
acute tubular necrosis
alive and we ll
B
BG
blood glucose
BGL
bid
blood glucose level
twice daily
BILAT
BK
BKA
bilateral or bi latera lly
below knee
below knee amputation
BLE
both lower extremities
BLS
basic life support
BM
bol
bowel movement; bone marrow
bol us
BP or B/P
blood pressure
BPH
ben ign prostatic hypertrophy
branch
bronchoscopy; bronchoscope
BS
BSA
breath sounds; blood sugar
body surface area
BVM
bag va lve mask
C-SPINE
cervica l spine
comp laint of, compla in s of, or com pl ai nin g of
c
C/0
CA
cancer; carcinoma
CAB
coronary artery bypass
CABG
CAD
coronary artery bypass graft
CAPO
CATH
coronary artery disease
continuo us ambulatory peritoneal dialysis
cathe t er
cc
ccu
chi ef comp laint, comp li cations and co-morbidities
critica l care unit
CHF
CICU
congestive heart fai lu re
cardiac (co rona ry) intensive ca re unit
CKD
chronic kidney disease
CNS
central nervous system
C02
carbon dioxide
COPD
chron ic obstructi ve pulmonary di sease
CP
chest pain
CPAP
CPR
continuous (constant) positive airway pressure
CRF
CSF
CT
cardiopu lm onary resusci tati on
chronic renal failure
cereb rospinal fluid
CT sca n
CVA
cerebra l vascu lar acciden t
CVD
CXR
cardiovascu lar disease
chest x-ray
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D
DSW
OAT
DO
decub
De cub
DKA
OM
DNR
DOA
DOB
DOE
DRG
DT
DVT
Ox
5% dextrose in water
diet as tolerated
differential diagnosis
lying down (decubitus)
decubitus ulcer
diabetic ketoacidosis
diabetes mellitus
do not resuscitate
dead on arrival I date of admission
date of birth
dyspnea on exertion
diagnosis related group
delirium tremens
deep vein thrombosi s
Diagnosis
E
EBL
EC
ECF
E coli
ECHO
ECMO
ECV
ECW
ED
EDC
edent
EEG
EENT
EF
EFA
EGA
EKG/ECG
estimated blood loss
enteric coated
extended care facility
Escherichia coli
echoca rdiogra m
extracorporeal membrane oxygenation
extracellular volume
extracellular water
emergency department
estimated date of confin ement
ESLD
ESRD
ET
ETOH
ETI
Exp
edentu lous
electroencepha logram
eye, ear, nose, throat
ejection fraction
essential fatty acids
estimated gesta ti ona l age
electroca rd iogra m
enzyme-linked immunosorbent assay (immunological testing)
enteral nutrition
epinephrine
erythropoietin
extrapyramidial symptom s
end stage liver disease
end stage renal disease
endotracheal tube
ethanol alcohol
endotra cheal tube
Expired
F
FAS
fema le
fetal alcohol syndrome
ELI SA
EN
EPI
EPO
EPS
F
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FB
FBS
FBG
FTP
FTI
F/U
FUO
Fx
foreign body
fa sting blood sugar
fa sting blood glucose
failure t o progress
failure to thrive
fo ll ow-up
fever of undetermined orig in
fracture
G
G
GB
GBD
GBS
GC
GERD
GFR
G
Gl
GLT
GSW
gtts
GU
GYN
gra ms
gallb ladder
gallb lad der disease
gallbladder se ri es
go nococcus
gastroesop hageal reflu x disease
glomeru lar filtration rate
gravida
gastroi ntesti na I
gut-associated lymphoid tissue
gunshot wound
drops
gastric ulcer
gynecology or gynecological
H
HA; H/A
HDN
HD
HEENT
hemi
HH
HHNKS
HI
HI V
HL
HLHS
H&N
H&P
H/0; h/o
HOH
HR
hs
headache
hem o lytic disease of the newbor n
hemod ialysis
head, eyes, ea rs, nose, throat
hemiplegia, hemip legic
hiata l hernia
hyperglycemic, hyperosomolar nonketotic synd rom e
head inju ry
hum an immunodefi cie ncy virus
hearing loss
hydroplastic left heart syndrome
hea d and neck
history and physical
history of
hard of hearing
heart rate per minute
HTN
Hx
bedtime
hype rte ns ion
hi story
IBD
IBS
ICP
ICU
inflammatory bow el disease
irritable bowel syndrome
intracranial pressure
intens ive care unit
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IGT
IH D
IM
INH
1&0
IUGR
IVP
IVPD
ISVD
IV
im pai red glu cose tolerance
isc hemi c heart disease
intramuscular
isoniazid
intake and output
intrauterine growth retardation
intravenous pyelography; intravenous push
intravenous piggyback
interventricular septal defect
JVD
jugular venous distension
kg
KLS
KUB
KVO
Ki logram
kidney, liver, sp leen
kidney, ureter, bl adder
keep ve in open
Intravenous
J
K
L
lap
laparot o my
LBBB
LBW
L-S PINE
L/S SPINE
L&D
LAT
lb
LES
LFT
LGA
LLQ
LMP
left bundle branch block
low birth weight
lumbar spine
lumbarsacral spine
labor and delivery
lateral
pound
lower esophageal sphincter
liver function t ests
large for gestational age
lower left quadrant
LOC
last menstrua l period
leve l of conscio usness
LOS
LP
LR
LR Q
LSH
LTC
LU Q
LVH
length of stay
lumbar puncture
lactated ringers
lower right quadrant
laparoscopic supracervical hysterectomy
long term care
left upper quadrant
left ventricu lar hypertrophy
M
MAO I
meg
MOD
MED
med-surg
Male
monamine oxidase inhibitor
micrograms
major depress ive disorder
medicine
medical-s urgical
M
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met(s)
mg
Ml
MICU
min
mmHg
MO
MOM
Mono
MR
MRSA
MRI
MS
MSI1
MVA
MVP
metastasis, metastasize, metastasizing
milligram
myocardial infarction
medical inten sive care unit
minute or minimum
millimeters of mercury {BP unit)
mineral oil; months old
milk of magnesia
monocyte; mononucleosis
magnetic resonance; medical records; mental retardation
methicillin resistant staph au reus
magnetic resonance imaging
mental status; muscular sclerosis; multiple sc lerosis
mental status change
motor vehicle acc ident
mitral valve prolapse
N/A
NAD
NAS
N/V
N/V/0
NAD
NC
NEB
NEC
NG{T)
NKA
NKDA
NOS
NPO
NRB
NS
NSAID
NSR
not availab le
no acute distress
no added salt
nausea and vomiting
nausea, vomiting, and diarrhea
no apparent distress
nasal cannula
nebulizer
necrotizing enterocolitis
nasogastric tube
no known allergies
no known drug allergies
not otherwise specified
nil per os (nothing by mouth)
non-rebreather
normal saline
nonsteroida l anti-inflammatory drug
normal sinus rhythm
02
OB
OBS
OB/GYN
OR
Ortho
02 sat
OT
OTC
oxygen
obstetrics
organic brain syndrome
obstetrics and gynecology
oral contraceptive
operating room
orthopedics
oxygen saturation
occupational therapy
over the counter
p
para; pulse
N
0
oc
p
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PA
P&A
PACU
Para
Path
PALP
PAC
p.c.
PCA
PCOD
PDA
PE
PERRLA
PEG
PFT
PH
PICC
PKU
PMH
PN
PO
POD#
Post-op
pp
PPBS
PR
Pre-op
PRN
Prog
PSA
PPT
PTA
PUD
pernicious anemia
percussion and auscultation
post anesthesia care unit
para (nullipara, primiparia, Para !, Para II, etc)
pathology
palpitation
premature atr ial contraction
after meals
patient-controlled analgesia
polycystic ovarian disease
patient ductus arteriosus
pulmonary embolus; physical examination ; pelvic exam
pupils equal, round, reactive to light
percutaneous endoscopic gastrostomy
pulmonary function test
past history
peripherally inserted centra l catheter
phenylketonuria
past medical history
parenteral nutrition
by mouth
postoperative day#
postoperative
postpartum; post-prandial
post-prandial blood sugar
P/Y; PT
per rectum
pre-operative
as needed
prognosis
prostate specific antigen
physical therapy
prior to arriva l
peptic ulcer disease
pulmonary
premature ventricu lar contraction
penicillin
pack year (cigarettes)
q
every
R
RA
rectal ; respiration ; right
rheumatoid arthritis; right atrium; room air
RBBB
Resp
RDS
Re
Rh
RIA
RLE
right bundle branch block
respiratory; respiration
respiratory distress syndrome
Pulm
PVC
PVN
Q
R
concerning
rhesus factor (will be+ or -)
radioimmunoassay
right lower extremity
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RLL
RLQ
R/0
ROM
ROS
RQ
RR
RRR
RT
RUE
RUQ
Rx
right lower lobe
right lower quadrant
rule out
range of motion; rupture of membranes
review of symptoms
respiratory quotient
respiratory rate
regular rate and rhythm
respiratory therapist; radiation therapy
right upper extremity
right upper quadrant
medicine, prescription
SAH
SB
SBE
SBO
S/P
S&S; S/S
ss, SS, SSE
ST
Staph
STD
stat
Strep
subarachnoid hemorrhage
small bowel
shortness of breath on exertion; subacute bacterial endocarditis
small bowel obstruction
sick le ce ll
small for gestat ional age
status post
syndrome of inappropriate antid iuretic hormone
sudden infant death syndrome
systemic lupus erythematous
significant other
signed out
shortness of breath
subjective, objective, assessment, plan
so lution
status post
signs and symptoms
soapsuds (enema )
sinus tachycard ia
sta phy loccus
sexua lly transmitted disease; short term disab ility
immediate ly
streptococcus
SubQ
Supp
Susp
SVT
Sx
Sz
subcutaneous
suppos itory
suspension
su praventricu Ia r tachycardia
symptoms
Seizures
T, temp
T ma x
temperature; time
maximum temperature
tab let
s
sc
SGA
S/P
SIADH
SIDS
SLE
so
S/0
SOB
SOAP
Sol
T
tab
tachy
TAH
TB
tachycardia
tota l abdom inal hysterectomy
tuberculosis
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TBSA
TBLC
TBW
THR
TLH
T-Spine
T
TI A
tid
TKO
TO
top
ta l
TPN
TURP
TWE
Tx
t ota l burn surface area
term birth, livi ng child
t ot al body wa t er
tota l hip replacement
t ota ll aparosco pi c hys t erectomy
thoracic spine
t emperature
trans ient isc hemi c att ack
three times a day
to kee p open
te lephone order
topical ly
to lerate, t o lerate d, t o lerance
total parenteral nutrition
tran surethral resecti on of prost ate
tap water ene ma
treatment
UAO
unk
UOA
UOP
UR
UR I
Ural
US; U/S
UTI
uppe r airway obstru ct ion
unknown
upon or arriva l
uri nary outp ut
upper respiratory; uti li zation review
upper respira t ory infection
uro logy; urologist
ultrasound
uri nary t ract in fect io n
V/D
Vent
VF
Vi z
VH
VLBW
VT
vomiting and diarrhea
ventra l; ventricu lar; ventilator
ve ntricular f ibrill ation
that is; name ly
vag ina l hyst erect omy
ve ry low birth weig ht
verbal order
oxyge n cons umpti o n
vo lume
vancomycin resista nt staph aure us
vita l signs
ventricu Ia r tachycardia
WB
WC; w/c
w/d
WD
WFL
WN ; w/n
WNL
weight bearing
w hee lchair
wel l developed; warm and dry
we ll deve loped
within functi onal lim its
well nourished
w ithi n normal limits
u
v
vo
V0 2
val
VRSA
vs
w
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W/U; w/u
we ight
work- up
X
ti mes
YO; y/o
YTD
years o ld
year to date
Wt
X
y
Symbols
+
>
<
posi t ive
negat ive
greate r t han
less th an
equa l
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DO NOT USE THE FOLLOWING ABREVIATIONS
Common Medical Abbreviation Medical errors have been identified as the fourth most common cause of patient
deaths in the United States. To help reduce the numbers of errors related to incorrect use of terminology, The
Joint Commission (TJC) formerly known as the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) issued a list of abbreviations, acronyms, and symbols that should no longer be used . The action supports
one of TJC's national patient safety goals : to improve the effectiveness of communications among caregivers . The
complete recommendations can be found on the TJC's website at http://www.jointcommission.org.
Abbreviation
U (for unit)
IU (for international unit)
Q.D.,
Q.O.D.
(Latin abbreviation for once daily
and every other day)
Trailing zero (X .O mg)
Lack of leading zero (.X mg)
Potential Problem
Mistaken as zero, four, or cc
Mistaken as IV (intravenous) or 10
(ten)
Mistaken for each other. The
period after the Q can be mistaken
for an " I" and the "0" can be
mistaken for "I" .
Decimal point is missed .
MS
MS04
MgS04
Confused for one another.
Can mean morphine sulfate or
magnesium sulfate.
flg
(for microgram)
Mistaken for mg (milligrams)
resulting in one thousand-fold
dosing overdose.
Mistaken for either half-strength or
hour of sleep (at bedtime) .
q.H .S. mistaken for every hour. All
can result in a dosing error.
Mistaken for three times a day or
twice weekly resulting in an
overdose.
H.S.
(for half-strength or Latin
abbreviation for bedtime)
T.I.W.
(for three times a week)
S.C. or S.Q.
(for subcutaneous)
Mistaken as SL for sublingual,
or " 5 every"
D/C
(for discharge)
Interpreted as discontinue
whatever medications follow
(typically discharge meds)
Mistaken for U (units) when poorly
written
Mistaken for OS, 00, and OU, etc.
c.c.
(for cubic centimeter)
A.S, A.D., A.U.
(Latin abbreviation for left, right, or
both ears)
Preferred Term
Write "unit"
Write "international unit"
Write "daily" and "every other day"
Never write a zero by itself after a
decimal point (X mg), and always
use a zero before a decimal point
(O .X mg)
Write "morphine sulfate" or
"magnesium sulfate"
Write "meg"
Write out "half-strength"
or
"at bedtime"
Write "three times weekly"
or
" 3 times weekly"
Write "Sub-Q", "subQ" , or
"subcutaneously"
Write "discharge"
Write "ml" for milliliters
Write : "left ear", "right ear" , or
"both ears"
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