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Charting
RCN approved medical terminology
Question | Answer |
---|---|
@ | at |
a (line over it) | before |
A.Fib. | atrial fibrillation |
abd | abdomen |
AAA | abdominal aoritc aneurysm |
AB | abortions (termination of pregnancy) |
ABG | arterial blood gas |
ADA | American Diabetic Association |
ad lib | as often as desired, as needed |
ADL | activities of daily living |
AK | above the knee |
AKA | above the knee amputation |
amb | ambulatory |
amt | amount |
ant | anterior |
ante | before |
ASAP | as soon as possible |
b/min | beats per minute |
BBB | bundle branch block |
BKA | below knee amputation |
BP | blood pressure |
BM | bowel movement |
BR | bathroom |
BRP | bathroom priviletes, up to bathroom only |
Bx | biopsy |
C1-7 | cervical vertebra |
C | celsius |
c (line over it) | with |
CABG | coronary artery bypass graph |
cath | catheter |
C.B.I. | continuous bladder irrigation |
cm | centimeter |
C/O or c/o | compains of |
commode | bedside toilet |
CPAP | continuous positive airway pressure |
CPR | cardio-pulmonary resuscitation |
DOA | dead on arrival |
dangle | sit at edge of bed, legs over side |
dc | discontinue |
decub | decubitis (lying) position |
defib | defibrillation |
DNR | do not resuscitate |
D.O. | Doctor of osteopathy |
DPT | ditheria, pertussis, tetanus |
Drsg | dressing |
Dx | diagnosis |
EBL | estimated blood loss |
ENT | ear, nose and throat |
E.T. tube | endotracheal tube |
exam | examination |
Ext. | external |
F | female |
F. | Fahrenheit |
F.U.O | fever of unknown origin |
FX | fracture |
ga | gauge |
GI | gastrointestinal |
Gm | gram |
G.N. | graduate nurse |
Grav (I,II,...ect.) | number of pregnancies, gravida |
GSW | gun shot wound |
G-Tube | gastric feeding tube/gastrostomy tube |
GU | Genitourinary |
H & P | history and physical |
Hg | mercury |
H & H | hemoglobin and hematocrit |
Hb or Hbg | hemoglobin |
Hct. | hematocrit |
Htn | hypertension |
ht | height |
Hx | history |
h, hr. | hour, hours |
int | internal |
I & D | incision and drainage |
I & O | intake and output |
I.D. | identification and or identify |
IUD | intra-uterine device |
irrig | irrgate, irrigation |
JVD | jugular vein distention |
kg | kilogram |
KUB | kidney, ureter, bladder (x-ray) |
L1-5 | Lumbar vertebrae or nerves |
Lami | laminectomy |
LLE | left lower extremity |
LLQ | lower left quadrant (abdomen) |
L.P.N. | Licensed Practical Nurse |
LUE | left upper extremity |
L | left |
Lt | left |
l | liter |
l/min | liters per min |
lat | lateral |
lbs. | pound |
m | meter |
M.D. | Medical Doctor |
MRSA | methicillin resistant staph aureus |
mcg | microgram |
MCL | midclavicular line |
mEq or meq | milliequivalent |
min | minute |
misc. | miscellaneous |
ml | milliliter |
mm | millimeter |
mmHg | millimeters of Mercury |
mo | month |
mod | moderate |
NCB | no code blue |
NH | nursing hom |
N & V | nausea and vomiting |
N.K.D.A | no known drug allergies |
N.P.O | nothing by mouth |
NSR | normal sinus rhythm |
N.T | nasotracheal |
n/a | not applicable |
NC | nasal cannula |
neg | negative |
NG | nasogastric |
O.J. | orange juice |
O2 | oxygen |
PCT | patient care technician |
P.E. | physical exam |
P.D. | postural drainage |
P.I. | present illness |
POD | post-operative day |
PRBC | packed red blood cells |
P.T.A | prior to admission |
per | by or through |
PERL | pupils equal and react to light |
PERLA | pupils equal, react to light accomodation |
PERRLA | pupils equal, round, reactive to light and accomodation (eyes) |
PH | past history |
PND | paroxysmal nocturnal dyspnea |
PTD | prior to discharge |
PVC | premature ventricular contraction |
p | pulse |
p (line over it) | after |
pos | positive |
poss | possible |
Post | posterior |
Prep. | preparation, prepare |
pt. | patient |
q | every |
qns | quanity not sufficient |
qs | quanity sufficient |
ques | question |
R | respirations |
circled R | right |
RAI | radioactive iodine |
RLE | right lower extremity |
R.L.Q. | right lower quandrant (abdomen) |
R.N. | Registered Nurse |
R/O | rule out |
ROM | range of motion |
ROS | review of systems |
RTO | return to office |
RUE | right upper extremity |
RUQ | right upper quadrant (abdomen) |
RV | residual volume |
Reg | regular |
rbc | red blood cells |
Rx | recipe (perscription) |
SaO2 | saturated oxygen |
S1-5 | sacral vertebra |
SBO | small bowel obstruction |
s (line over it) | without |
S/S or S & S | signs and symptoms |
sero-sang | sero-sanguinous |
SIDS | sudden infant death syndrome |
sl | slight |
staph or Staph | staphylococcus |
Surg | surgery |
Sx | symptoms |
T1-12 | thoracic vertebra |
T or Temp (ax,o,r) | temperature (axillary, oral, rectal) |
T & C | type and cross |
TKA | total knee arthroplasty |
TMJ | temporomandibular joint |
tol | tolerated |
TPR | termperature, pulse, respiration |
trach | tracheostomy |
tx | treatment |
UE | upper extremity |
UGI | uppergastrointestinal |
umb | umbilical/umbilicus |
US | ultra sound |
V.O. | verbal order |
V.S. | vital signs |
vag | vaginal |
vent | ventilator |
Vit | vitamin |
VRE | vancomycin resistant enterococcus |
WNL | within normal limits |
wbc | white blood cell |
w/c | wheelchair |
w/o | without |
wt | weight |
X | times |
x-ray | radiology |
yell | yellow |
yest | yesterday |
y/o | years old |
yr. | year |
YTD | year to date |