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Common Medical Notations

General
_ _
c = with _s = without
PRN = as needed p = after
NTE = not to exceed
Frequency of Medications or Other Activities (i.e., labs, inspiratory
spirometry, ambulation, etc.)
Q = every QHS = at night
BID = twice daily QAM = in morning
TID = three times daily QID = four times daily
BID, TID, and QID are not equivalent to q12h, q8h, or q6h
Route of Medications
PO = by mouth NPO = nothing by mouth
IV = intravenous SQ = subcutaneous
PR = per rectum
Normal Physical Exam
GEN:
AOx3 (alert and oriented)
sick vs. not sick/ill-appearing
HEENT (head/eye/ear/nose/throat):
NC/AT (normocephalic atraumatic)
PERRLA (pupils equal round reactive to light and accommodation)
EOMI (extraocular movements intact)
O/P clear (oropharynx)
Neck:
Na Cl BUN
supple Glucose
K HCO3 Cr
Ø thyromegaly
Ø LAD (lymphadenopathy) PT
INR
CV: Hgb PTT
RRR (regular rate & rhythm) S1, S2 WBC plts
Hct
Ø M/R/G (murmurs/rubs/gallops) T.Bili
Chest: AST ALT
Alk
CTAB (clear to auscultation bilaterally) Write out
Ca, Mg, and PO4 Phos Albumin
Ø W/R/R (wheezes/rhonchi/rales)
ABD:
S/NT/ND (soft/non-tender/non-distended)
Ø R/G (rebound/guarding)
⊕ BS (bowel sounds)
Ø masses
Ø HSM (hepatosplenomegaly)
EXT:
Ø C/C/E (clubbing/cyanosis/edema)
Skin:
WD (warm & dry)
Ø visible lesions
Neuro:
non-focal
CN 2-12 intact (cranial nerves)

“Do Not Use” Abbreviations


The Joint Commission for Accreditation of Healthcare Organizations (JCAHO)
has established National Patient Safety Goals to improve patient safety. Beginning
January 1, 2004, JCAHO has indicated that the following abbreviations may not be
used in ANY hand-written, patient-specific communication, including and not limited
to: medication and treatment orders, medication and treatment administration records,
laboratory and radiology orders, progress notes, etc.

Abbreviation Please use Rectifies Problem:


(Do NOT use)
U (for unit) Write “unit” Mistaken as zero, four, or cc
IU (for Write Mistaken as IV (intravenous)
international unit) “international unit” or 10 (ten)
QD or QOD Write “daily” and Mistaken for each other and for QID.
“every other day” The period after the Q in “QD” can
be mistaken for an “I” and the “O” in
“QOD” can be mistaken for “I”
Trailing zero Never write a zero Decimal point is missed.
(X.0 mg) by itself after a (10-fold increase in value)
decimal point (X mg)
Lack of leading Always use a zero Decimal point is missed.
zero (.X mg) before a decimal (10-fold increase in value)
point (0.X mg)
MS or MSO4 Write “morphine sulfate” Confused for one another.
or MgSO4 or “magnesium sulfate” Can mean morphine sulfate or
magnesium sulfate.
µg (microgram) Write “mcg” Mistaken as “mg” (milligram)
General Guide to Writing Prescriptions
You will often be required to write medication orders. This will either be on
admission orders, medicine you would like to begin, or discharge medications. There
are roughly two categories:
1. Scheduled medications (PO, IV, or other)
2. PRN medications (as needed, i.e., Benadryl, Tylenol, etc.)

You must have, in this order:


1. Patient name and I.D.
2. Time / date of order
3. Name of medicine
4. Dose of medicine (milligrams)
5. Number of tablets of that dosage
6. Route of administration
7. Frequency of dosage

Special note:
1. PRN meds: you need to specify: the dose (i.e. 325 mg); the number of
tablets (i.e. = 1-2); how often the patient can receive these (i.e., every 6
hours = q 6°); as well as the specific indication for the medicine. For
example: Tylenol 325 mg PO q 4-6 ° PRN headache, temp > 38.5
Always think about NTE (not to exceed) and hold orders!
2. IV medicines are generally written in hourly increments. For example, if the
medicine should be given every 8 hours, it should be written specifically as
q 8°, NOT TID, because TID is three times daily, which doesn’t necessarily
mean every 8 hours.

Additional references
Nerd’s Guide to Pre-Rounding: Rick Loftus ’01, a resident in the UCSF
Department of General Internal Medicine – Primary Care, has prepared an additional
document about life on the wards. The “Nerd’s Guide to Pre-Rounding” (version 2.01)
can be found at http://medstudents.ucsf.edu under “Clinical Guide.”
First Aid for the Wards and 101 Biggest Mistakes 3rd Year Medical Students Make:
If you’re ambitious, read these before each rotation for tips and general knowledge.
UCSF’s Internal Medicine Hospitalist/Housestaff Handbook: This invaluable
guide and resource for the clerkships is available to download in a Palm/PocketPC
version at http://medicine.ucsf.edu/housestaff/handbook