Download Using Abbreviations 3

Abbreviations
Abbreviations are used as a time and space saver while in writing notes. In order to ensure that everyone in
the clinical setting can understand what has been written in the chart by others, most medical facilities have a
list of approved abbreviations, and these are the only abbreviations that should reused in a medical record in
that particular facility. The list of abbreviations should be approved by the medical records department of each
facility The list of acceptable abbreviations varies from one facility to the next, particularly terminology specific
to allied health fields such as physical and occupational therapy.
The list of abbreviations that follows is a compilation of the most common abbreviations used by over 13
different healthcare facilities.
ant
AP
AROM
ASA
ASAP
ASHD
ASIS
assist.
assessment
active assistive range of motion
abduction
before meals
acromioclavicular joints
adrenocorticotrophic hormone
adduction
activities of daily living
at discretion
admission
above elbow
ankle foot orthosis
autoimmune deficiency syndrome
anterior inferior iliac spine
ankle jerk
above knee
morning
against medical advice
ambulation, ambulating,
ambulated, ambulate, ambulance
anterior
anterior - posterior
active range of motion
aspirin
as soon as possible
ateriosclerotic heart disease
anterior superior iliac spine
assistance, assistive
B/S
BE
bid
bilat.
BK
BM
BP
bpm
BRP
BUN
beside
below elbow
twice a day
Bilateral, bilaterally
below knee
bowel movement
blood pressure
beats per minute
bathroom privileges
blood urea nitrogen (blood test)
A:
AAROM
abd
ac
AC joints
ACTH
add
ALL
ad lib
adm
AE
AFO
AIDS
AIIS
AJ
AK
a.m.
AMA
amb
CP
CPR
CSF
CV
CVA
CWI
Cysto
Centigrade
culture and sensitivity
cancer, carcinoma
coronary artery bypass graft
coronary artery disease
calories
complete blood count
closed brain injury
chronic brain syndrome
chief complaint
cubic centimeter
congestive heart failure
centimeter
central nervous system
complains of
carbon dioxide
chronic obstructive lung disease
continue
chronic obstructive pulmonary
disease
certified occupational therapy
assistant
cerebral palsy
cardiopulmonary resuscitation
cerebral spinal fluid
cardiovascular
cerebrovascular accident
crutch walking instructions
cystoscopic examination
dept.
DIP
D/C
DM
DO
DTR
Dx
department
distal interphalangeal joint
discontinued or discharged
diabetes mellitus
doctor of osteopathy
deep tendon reflex
diagnosis
ECF
extended care facility
C
C&S
CA
CABG
CAD
cal
CBC
CBI
CBS
CC, C/C
cc
CHF
cm
CNS
c/o
CO 2
COLD
cont.
COPD
COTA
ECG, EKG
EEG
EENT
EMG
E.R.
eval.
ext.
electrocardiogram
electroencephalogram
ear, eyes, nose, throat
electromyogram,
electromyography
emergency room
evaluation
extension
FUO
FWB
fx
fair (muscle strength, balance)
fasting blood sugar
family history
flexion
foot, feet (the measurement not the
body part)
fever, unknown origin
full weight bearing
fracture
G
GB
GI
gm
GYN
good (muscle strength, balance)
gallbladder
gastrointestinal
gram
gynecology
h, hr.
H & H, H/H
H&P
HA, H/A
Hb, Hgb
HCVD
HEENT
HEP
HI
HIV
HNP
HOB
HR
hr.
hs
ht.
Ht
Htn
Hx
hour
hematocrit and hemoglobin
history and physical
headache
hemoglobin
hypertensive cardiovascular
disease
head, ear, eyes, nose, throat
home exercise program
head injury
human immunodeficiency virus
herniated nucleus pulposus
head of bed
heart rate
hour
at bedtime
height
hematocrit
hypertension
history
I&O
ICU
IM
imp.
intake and output
intensive care unit
intramuscular
impression
F
FBS
FH
flex
ft.
in.
indep
inf
IV
inches
independent
inferior
intravenous
kcal
kg
KJ
KUB
kilocalories
kilogram
knee jerk
kidney, ureter, bladder
L,l.
(L)
lb.
LBP
LE
LOC
LP
liter
left
pound
low back pain
lower extremity
loss of consciousness
lumbar puncture
m
max
MD
MED
Meds.
MFT
mg
MI
min
min.
ml
mm
MMT
mo.
mod
MP, MCP
MS
meter
maximal
medical doctor; doctor of medicine
minimal erythemal dose
Medications
muscle function test
milligram
myocardial infarction
minimal
minutes
milliliter
millimeter
manual muscle test
month
moderate
metacarpalphalangeal
multiple sclerosis
N
NDT
neg.
N.H.
noc
npo
NSR
NWB
normal (muscle strength)
neurodevelopmental treatment
negative
nursing home
night, at night
nothing by mouth
normal sinus rhythm
non-weight bearing
O:
OB
OBS
od
O.P
objective
obstetrics
organic brain syndrome
once daily
out patient
O.R.
ORIF
OT
OTR
oz.
operating room
open reduction, internal fixation
occupational therapy, occupational
therapist
occupational therapist (used to
follow official signature of the
occupational therapist)
ounce
PT/PTT
Pt.,pt
PTA
PTB
PVD
PWB
poor (muscle strength, balance)
plan (treatment plan)
physician assistant
posterior/anterior
paraplegia
after meals
by/through
by mouth
pupils, equal, round, reactive to
light and accommodation
past history
afternoon
proprioceptive
neuromuscular
facilitation
peripheral nerve injury
problem-oriented medical record
positive
possible
posterior
after surgery (operation)
progressive resistive exercise
before surgery (operation)
whenever necessary
passive range of motion
posterior superior iliac spine
physical therapy, physical
therapist (used after therapist’s
signature; varies from facility to
facility)
protime/prothrombine time
patient
physical therapist assistant
prior to admission
peripheral vascular disease
partial weight bearing
q
qd
qh
qid
qn
every
every day
every hour
four times a day
every night
P
P:
P.A.
PA
para
pc
per
per os, p.o.
PERRLA
P.H
p.m.
PNF
PNI
POMR
pos.
poss
post
post op
PRE
pre-op
prn
PROM
PSIS
PT
qt.
Quart
(R)
RA
RBC
R.D.
re:
rehab
reps
resp
RN
R/O
right
rheumatoid arthritis
red blood cell count
registered dietician
regarding
rehabilitation
repetitions
respiratory, respiration
registered nurse
rule out (In order to make a good
diagnosis, the physician will try to
rule the disease/condition named
out; if he or she cannot, this will
become the diagnosis.)
range of motion
review of systems
resistive range of motion
respiratory therapist, respiratory
therapy
treatment, prescription, therapy
ROM
ROS
RROM
R.T.
Rx
SACH
SCI
SC joint
sec.
SED
sig
SI(J)
SLE
SLR
SNF
SOAP
SOB
S/P
spec
stat.
Sx
T
tab
TB
tbsp.
TENS, TNS
solid ankle cushion heel
spinal cord injury
sternoclavicular joint
seconds
subcrythemal dose
directions for use, give as follows,
let it be labeled
sacroiliac (joint)
systemic lupus erythematosus
straight leg raise
skilled nursing facility
subjective, objective, assessment,
plan
shortness of breath
status post (example: S/P (L) hip
fx means Pt. fx her hip in the
recent past)
specimen
immediately, at once
symptoms
trace (muscle strength)
tablet
tuberculosis
tablespoon
transcutaneous electrical nerve
stimulator
t.o.
TPR
tsp.
TUR
total hip replacement
transient ischemic attack
three times daily
total knee replacement
temporomandibular (joint)
tonic neck reflex (also ATNR
STNR)
telephone order
temperature, pulse & respiration
teaspoon
transurethral resection
UA
UE
UMN
URI
US
UTI
UV
urine analysis
upper extremity
upper motor neuron
upper respiratory infection
ultrasound
urinary tract infection
ultraviolet
c
s
p
a
~ or
@
VD
v.o.
vol.
v.s.
venereal disease
verbal orders (example: v.o Dr.
Smith/your signature)
volume
vital signs

>
<
=
+
w/c
W/cm2
WBC
wk.
WNL
wt.
wheelchair
watts per square centimeter
white blood cell count
week
within normal limits
weight
-
x
number of times performed
(X=twice, X3 = 3times)
y/o or y.o.
yd.
yr
years old
yard
year
THR
TIA
tid
TKR
TM(J)
TNR
+1, +2


//
#
/
%
+, &, et
,

1°
2°
assistance (assistance of 1 person
given; also written “assistance of
1”) (Examples: amb…with + 1
assist., or amb…with +1 min
assist., or amb… with min of
assist. of 1)
male
female
down, downward, decrease,
diminished
up, upward, increase, augmented
parallel or parallel bars (also
written / / bars)
with
without
after
before
approximately
at (this symbol is not exclusively
used for at)
change
greater than
less than
equals
plus, positive (positive also
abbreviated post)
minus, negative (negative also
abbreviated neg.)
number (#1 = number 1), pounds
(5# wt. = 5 pound weight; also
abbreviated lbs.)
per
percent
and
to and from
to, progressing toward,
approaching
primary
secondary, secondary to