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Charting

RCN approved medical terminology

QuestionAnswer
@ 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
Created by: ericabourbon
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