Common Medical Abbreviations 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 Web site at: www.jcaho.org/accredited%2Borganizations/patient%2Bsafety/04%2Bnpsg/04_npsg.htm. The following is a list of commonly used medical abbreviations that are being used in medical documentation. This list is not all inclusive, nor is it intended to instruct users to apply only these abbreviations when documenting the medical record. Documenting the entire condition, cause, disease, or syndrome is always best practice in medical documentation. AAA- abdominal aortic aneurysm ABG- arterial blood gasses ADL- activities of daily living AEA- above the elbow amputation AF-atrial fibrillation AFib-atrial fibrillation AFlut-atrial flutter AI- aortic insufficiency AIDS-acquired immunodeficiency syndrome AKA-above the knee amputation ALCL- anaplastic large cell lymphoma ALL- acute lymphoid leukemia ALS- amyotrophic lateral sclerosis aka. Lou Gehrig’s Disease AMI-acute myocardial infarction AML- acute myeloid leukemia A/O-alert and oriented AODM- adult onset diabetes mellitus APS-anaphylactic shock ARDS- acute respiratory distress syndrome ARF- ***acute respiratory failure or acute renal failure*** ASHD- arteriosclerotic heart disease AVR- aortic valve replacement AWS-alcohol withdrawal syndrome BBB-bundle branch block BCC- basal cell carcinoma BEA-below the elbow amputation b.i.d.- twice daily BKA- below the knee amputation CK-creatinine kinase BMI-body Mass Index BMR- basal metabolic rate BMT-bone marrow transplant BP-blood pressure BPH-benign prostatic hypertrophy BPM-beats per minute BS-**blood sugar, breath sounds, bowel sounds** BSA-body surface area BUN-blood urea nitrogen Bx-biopsy CA-cancer or carcinoma CABG-coronary artery by-pass graft CAD-coronary artery disease CAP-community acquired pneumonia CAPD-continuous ambulatory peritoneal dialysis Card Cath-cardiac catheterization CAT-computerized axial tomography Cath-catheterization, catheter CBC-complete blood count CC-chief complaint CD-Crohn’s Disease CF-cystic fibrosis CGS-cardiogenic shock CHD-**congenital heart disease or coronary heart disease** CHF-congestive heart failure Chr-chronic CIS-carcinoma in-situ Common abbreviations used in medical coding CLL-chronic lymphoid leukemia CM-***cardiomyopathy or cardiomegaly*** CML-chronic myeloid leukemia CMV-cytomegalovirus CNS-central nervous system c/o- complains of COPD-chronic obstructive pulmonary disease Cor-heart CP-cerebral palsy CPAP-continuous positive airway pressure CPK-creatinine phosphokinase CPR-cardiopulmonary resuscitation CRBSI-catheter related bloodstream infection CRF-***chronic respiratory failure or chronic renal failure*** C&S-culture and sensitivity CSF-cerebrospinal fluid CT-computerized tomography CVA-cerebrovascular accident CVC-central venous catheter CXR-chest x-ray DBP-diastolic blood pressure d/c-discontinue DDD-degenerative disk disease DIC-disseminated intravascular coagulation DJD-degenerative joint disease DKA-diabetic ketoacidosis DLE-disseminated lupus erythematous DM-diabetes mellitus DOE-dyspnea on exertion DT-delirium tremens DTR-deep tendon reflexes DVT-deep vein thrombosis Dx- diagnosis ECG/EKG-electrocardiogram ESA-erythropoiesis stimulating agents ESR-erythrocyte sedimentation rate ESRD-end stage renal disease ETOH- ethanol alcohol FBS-fasting blood sugar Fx-fracture GC-gonococcus GCS-Glasgow Coma Scale GERD-gastroesphageal reflux disease GFR-glomerular filtration rate Gm+-gram positive Gm- -gram negative GTT-glucose tolerance test GVH-graft versus host disease H/A-headache LVF-left ventricular failure HB or Hgb-hemoglobin HCL-harry cell leukemia Hct-hematocrit HD-Hodgkin’s disease or Hodgkin’s lymphoma HDL-high density lipoproteins HEENT-head, eyes, ears, nose, throat HF-heart failure HIV-human immunodeficiency virus H/O-history of H&P -history and physical HPI –history of present illness HR-heart rate HS-hours of sleep or bedtime HTN-hypertension HVD-hypertensive vascular disease HVS-hypovolemic shock Hx-history ICP-intracranial pressure ICS-intercostal space I&D-incision and drainage I/E-inspiratory, expiratory IM-intramuscular I&O-intake and output IOP-intraocular pressure IRDS-idiopathic respiratory distress syndrome IV-intravenous(ly) IVD-ischemic vascular disease IVPB-intravenous piggyback J-P-Jackson Pratt drain JRA-juvenile rheumatoid arthritis KS-Kaposi’s Sarcoma KSHV-Kaposi’s Sarcoma with herpes virus KUB-kidney, ureter, bladder KVO-keep vein open LBBB-left bundle branch block LBP-low back pain LCL-large cell lymphoma LDL-low density lipoproteins (bad cholesterol) LE-**Lupus Erythematous or lower extremity** LHF-left heart failure LLE-left lower extremity LLL-left lower lobe LLQ-left lower quadrant LOC-loss of consciousness LP-lumbar puncture LRQ-lower right quadrant LS-lymphosarcoma LUE-left upper extremity Common abbreviations used in medical coding LUL-left upper extremity LUQ -left upper quadrant LVSD-left ventricular systolic dysfunction MAL-malignant MCC-merkle cell carcinoma MCL-mantel cell lymphoma PERRLA-pupils equal, round, reactive to light and accommodation PET-positron emission tomography PFT-pulmonary function test SCD-sickle cell disease PH-past history PKD-polycystic kidney disease MCLS-mucotaneous lymph node syndrome, aka. Kawasaki disease PMH-past medical history MD-muscular dystrophy MDD-major depressive disorder MDI-metered dose inhaler MDS-myelodysplastic syndrome Mets-metastasis MG-myasenthia gravis MI-***myocardial infarction or mitral insufficiency*** MODS-multiple organ dysfunction syndrome MRI-magnetic resonance imaging MS-multiple sclerosis MVP-mitral valve prolapsed NAD-no apparent distress NCS-nerve conduction study NERD-no evidence of recurrent disease NF-neurofibromatosis NIDDM-non insulin dependent diabetes mellitus NKA-no known allergies NKDA-no known drug allergies PMI-past medical information p.o.-by mouth POMR-problem oriented medical record PRBC-packed red blood cells PRN-as needed prosth.-prosthesis PSH-past surgical history PUD-peptic ulcer disease (easily confused with PVDperipheral vascular disease) PVT-paroxysmal ventricular tachycardia q-every q.d.-every day q.h.-every hour quad.-quadriplegic RA-rheumatoid arthritis RBBB-right bundle branch block RBC-red blood cells RCS-reticulum cell carcinoma NLPHL-nodular lymphocyte predominant Hodgkin’s lymphoma RDS-respiratory distress syndrome NOS-not otherwise specified NPO-nothing by mouth NSA-no significant abnormality NSAID-nonsteroidal anti-inflammatory drug NSR-normal sinus rhythm NSTEMI-non ST elevated myocardial infarction N&V-nausea and vomiting NVD-nausea, vomiting, diarrhea NYClass I-IV- New York Class 1-4 disease heart failure OA-osteoarthritis OD-right eye O/E-on examination OS-left eye OTC-over the counter OU-both eyes OV-office visit PA-physician’s assistant PAF-paroxysmal atrial fibrillation PAT-paroxysmal atrial tachycardia p/c or p.c.-after meals PD-Parkinson’s disease PE-pulmonary embolism PEEP-positive end expiratory pressure RF-**respiratory failure or renal failure** RHD-rheumatic heart disease RHF-right heart failure RLE-right lower extremity RLL-right lower lobe RLQ-right lower quadrant r/o-rule out ROS-review of systems RRT-renal replacement therapy RSR-regular sinus rhythm RUE-right upper extremity RUL-right upper lobe RUQ-right upper quadrant Rx-prescription SB-spina bifida SBO-small bowel obstruction SCC-**squamous cell carcinoma or sickle cell crisis** sed rate-erythrocyte sedimentation rate SIDS-sudden infant death syndrome SIRS-systemic inflammatory response syndrome SLE-systemic lupus erythematous SOAP-subjective, objective, assessment, plan SOB-shortness of breath Common abbreviations used in medical coding Schiz-schizophrenia SS-septic shock SSS-sick sinus syndrome STAT-immediately STD-sexually transmitted disease STEMI-ST elevated myocardial infarction SVT-supra ventricular tachycardia T&A-tonsils and adenoids TB-tuberculosis T&C-type and crossmatch TEE-transesophageal echocardiography THR-total hip replacement TIA-transient ischemic attack t.i.d.- three times a day TKR-total knee replacement TLC-total lung capacity TPN-total parenteral nutrition TPR-temperature, pulse, respirations TSS-toxic shock syndrome TURB-transurethral resection of the bladder TURP-transurethral resection of the prostate Tx-treatment U/A-urinalysis UC-ulcerative colitis UE-upper extremity Vflut-ventricular flutter ULQ-upper respiratory infection URI-upper respiratory infection URQ-upper right quadrant US-ultrasound UTI-urinary tract infection Vfib-ventricular fibrillation VLDL-very low density lipoproteins VS-vital signs VSA-vital signs absent VSS-vital signs stable VT or VTach- ventricular tachycardia VTE-venous thromboembolism WBC-white blood count w/c-wheelchair WNL-within normal limits 3HB-3rd degree heart block **Note: Abbreviations in italics have more than one meaning. Please use other content to assure the correct meaning. Y0071_13_17201_I 5/10/2013 37638MUPENMUB Anthem Blue Cross is the trade name of Blue Cross of California: Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross names and symbols are registered marks of the Blue Cross Association.