Medicare Advantage
Risk Adjustment and Coding Academy
Coding | Risk Adjustment | Documentation | Training
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: http://www.jointcommission.org/facts_about_the_official_/
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.
**Note: Abbreviations in italics have more than one meaning. Please use other content to assure the correct
meaning.
A
AAA- abdominal aortic aneurysm
ABG- arterial blood gasses
ADL- activities of daily living
AEA- above the elbow amputation
AF- 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
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B
BBB- bundle branch block
BCC- basal cell carcinoma
BEA- below the elbow amputation
b.i.d.- twice daily
BKA- below the knee amputation
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
C
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
CK- creatinine kinase
CLL- chronic lymphoid leukemia
CM- ***cardiomyopathy or cardiomegaly***
CML- chronic myeloid leukemia
CMV- cytomegalovirus
CNS- entral 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
D
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
E
ECG/EKG- electrocardiogram
ESA- erythropoiesis stimulating agents
ESR- erythrocyte sedimentation rate
ESRD- end stage renal disease
ETOH- ethanol alcohol
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F
FBS- fasting blood sugar
Fx- fracture
G
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
H/A- headache
HB or Hgb- hemoglobin
HCL- harry cell leukemia
H H&P -history and physical R-heart rate
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
Hct- hematocrit
HPI –history of present illness
HS- hours of sleep or bedtime
HTN- hypertension
HVD- hypertensive vascular disease
HVS- hypovolemic shock
I
ICP- intracranial pressure
ICS- ntercostal 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
J-P - Jackson Pratt drain
JRA- juvenile rheumatoid arthritis
K
KS- Kaposi’s Sarcoma
KSHV- Kaposi’s Sarcoma with herpes virus
KUB- kidney, ureter, bladder
KVO- keep vein open
L
LUL- left upper extremity
LUQ –l eft upper quadrant
LVF- left ventricular failure
LVSD- left ventricular systolic dysfunction
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
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M
MAL-malignant
MCC- merkle cell carcinoma
MCL- mantel cell lymphoma
MCLS-mucotaneous lymph node syndrome, aka. Kawasaki disease
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
N
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
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
NLPHL- nodular lymphocyte predominant Hodgkin’s lymphoma
NY Class I-IV- New York Class 1-4 disease heart failure
NOS- not otherwise specified
O
OA- osteoarthritis
OD- right eye
O/E- on examination
OS- left eye
OTC- over the counter
OU- both eyes
OV- office visit
P
PA- physician’s assistant
PAF- paroxysmal atrial fibrillation
PAT- paroxysmal atrial tachycardia
p/c or p.c.- after meals
PD- Parkinson’s disease
PEEP- positive end expiratory pressure
PERRLA- pupils equal, round, reactive to light and accommodation
PET- positron emission tomography
PFT- pulmonary function test
PH- past history
PKD- polycystic kidney disease
PMH- past medical history
PMI- past medical information
p.o.- by mouth
POMR- problem oriented medical record
PE- pulmonary embolism
prosth.- prosthesis
PSH- past surgical history
PUD- peptic ulcer disease (easily confused
with PVD-peripheral vascular disease)
PVT- paroxysmal ventricular tachycardia
Q
q- every
q.d.- every day
q.h.- every hour
quad.- quadriplegic
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R
RA- rheumatoid arthritis
RBBB- right bundle branch block
RBC- red blood cells
RCS- reticulum cell carcinoma
RDS- respiratory distress syndrome
RF-**respiratory failure or renal failure**
RHD- heumatic 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
S
SB- spina bifida
SBO- small bowel obstruction
SCC-**squamous cell carcinoma or sickle cell crisis**
Schiz- schizophrenia
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
SS- septic shock
SSS- sick sinus syndrome
STAT- immediately
STD- sexually transmitted disease
STEMI- ST elevated myocardial infarction
SVT- supra ventricular tachycardia
T
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
U/A- urinalysis
UC- ulcerative colitis
UE- upper extremity
ULQ- upper respiratory infection
URI- upper respiratory infection
URQ- upper right quadrant
US- ultrasound
UTI- urinary tract infection
V
Vfib- ventricular fibrillation
Vflut- ventricular flutter
VLDL- very low density lipoproteins
VS- vital signs
VSA- vital signs absent
VSS- vital signs stable
VT or V Tach- ventricular tachycardia
VTE- venous thromboembolism
W
WBC- white blood count
w/c- wheelchair
Others:
WNL- within normal limits
3HB-3rd degree heart block
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