COMMONLY USED ACCEPTABLE MEDICAL AND Dosage and Application

HOSPITAL ABBREVIATIONS
gtt ---------- drops (guttae)
Time of Administration
OS ---------- left eye (oculus sinister);
ac ---------- before meals (ante cibum)
kg ---------- kilogram, a thousand grams
q4h ---------- every 4 hours
OU ---------- both eyes
pc ---------- after meals (post cibum)
L. ---------- a liter,
SIG.
IM ---------- intramuscular
od ---------- daily/once a day (omni die)
SC ---------- subcutaneous
qd ---------- EVERYDAY (QUAQUE DIE)
IV ---------- intravenous
Bid ---------- two times daily/twice
mL ---------- milliliter, a thousandth liter
Daily/2x a day (bis in die)
NPO (NBM) --- nothing by mouth
prn ---------- WHEN NECESSARY (PRO
RENATA) KSS ---------- Keep Set Sterile
Stat ---------- at once/immediately(statim) No. (#) ---------- number
AM ---------- morning (ante meridiem) KVO --------------- Keep Vein Open
PM ---------- afternoon (post meridiem) ID ---------- intradermal
Tid ---------- 3x a day Preparation of Drugs
Qid ---------- 4x a day Amp --------- ampule
h(hr) --------- hour (hora) Amt --------- amount
OM ---------- each morning Aq/H2O --------- water
qhs --------- at bed time (hora somni) Cap. --------- capsule
Alt. ---------- alternate days Dist. --------- distilled
Alt her ---------- alternate night S. or Sig. -------- give the following directions
M et N ---------- morning and nig Rx --------- take
Alt nect ---------- alternate nights C --------- with
Q ---------- every (quaque) S --------- without
QOD ---------- ALTERNATE DAY/ EVERY OTHER OD ---------- right eye (oculus dexter)
DAY
OS ---------- left eye (oculus sinister);
q1h ---------- every hour overdose
q2h ---------- every 2 hours OU ---------- both eyes
IV ---------- intravenous Neg ---------------- negative

Acceptable Initials and Abbreviations Commonly used symbols

Adm ----------------- admission ♀ ---------- female

Abd. ----------------- abdomen ♂ ---------- male

ADL ----------------- activities of daily living > ---------- greater than

Ad Lib --------------- as desired (ad libitum) < ---------- less than

Amb ----------------- ambulatory = ---------- equal

approx. ------------- approximately ↑ ---------- increased

CC ------------------ chief complaint ↓ ---------- decreased

C -------------------- Celsius ° ---------- degree

CBC ---------------- complete blood count @ ------------- at

Cl ------------------- client X ------------- times

c/o ------------------- complains of # ------------- number, fracture

CNS ----------------- central nervous system ō ------------- 0

CSF ------------------ cerebrospinal fluid

CO2 ----------------- carbon dioxide TERMS USED IN CHARTING

BP ----------------- blood pressure Abdomen

Concerning Concept to Suggested Terms
BR ----------------- bed rest
be Charted to be Used
BRP --------------- bathroom privileges Black and blue marks Bruised
present
BUN --------------- Blood Urea Nitrogen Hard, board-like Hard, rigid
Cldy ---------------- cloudy Filled with gas Tympanites
Appearance swollen Distended
DAT --------------- diet as tolerated Presence of rash Rash present
Hurts when touched Sensitive to touch,
D & C ------------- dilatation and curettage tender
DOA -------------- dead on arrival

I&O -------------- intake and output Admission or discharge of patient

Concerning Concept Suggested Terms to
Lab ---------------- laboratory to be Charted be Used
LMP -------------- last menstrual period Walking Ambulatory
Carried in (infant) Arm borne
Meds -------------- medication On stretcher Per stretcher
By wheelchair Per wheelchair
Mod --------------- moderate
Amount left)
Concerning Concept Suggested Terms to
to be Charted be Used
Attitude (mental)
Large amount Profuse, copious,
free, measured Concerning Concept Suggested Terms to
mount to be Charted be Used
Moderate amount Moderate, usual, Not interested in Indifferent
measured amount surroundings
Small amount Small amount, Has “don’t care” Apathetic
scanty, slight, very attitude
little, measured Suspicious, distrustful Doesn’t believe
amount anything said to
him/he
Quarrelsome, Belligerent,
Appearance disagreeable, wants quarrelsome.
Concerning Concept to Suggested Terms to argue Disagreeable
be Charted to be Used Afraid, worried Anxious, fearful
Thin, undernourished Emaciated Happy, carefree, Cheerful, optimistic
Fat, greatly overweight Obese cheerful
Seems very sick Acutely ill
Not very sick Not acutely ill
Back
Concerning Concept Suggested Terms to
Appetite to be Charted be Used
Concerning Suggested Terms to Upper back Interscapular region,
Concept to be be Used shoulder area
Charted Small back Lumbar region
Very fussy about Has like and dislike End of spine Sacral region
food, refuse to eat concerning food Gluteal area Buttocks
many food Hump back Kyphosis
Eats all food served Good appetite Sway back Lordosis
Eats very little Poor appetite
Loss of appetite Anorexic
Baths
Refuse to eat Refused food
(state reason) Concerning Concept Suggested Terms to
to be Charted be Used
Given when patient Admission bath
Arm is admitted
Concerning Concept Suggested Terms to All-inclusive bath Complete bath
to be Charted be Used Including face, arms, Partial bath
Shoulder to elbow Upper arm (right or axilla, genitalia
left) Special baths Name of bath
Elbow to wrist Lower arm (right or Taken in tub Tub bath
left) Taken in bed, by Self-administered,
Appear puffy and Edematous patient assisted with, bed
swollen bath
Artificial arm Prosthesis (right or Bleeding
 Concerning Suggested Terms to be with period of Apnea Respiration
Concept to be Used Large volume of air Deep breathing
Charted inhaled
Spurting of blood In spurts Small volume of air Shallow breathing
Very little Oozing inhaled
Nose blood Epistaxis Suffocation Asphyxia
Blood in vomitus Hematemesis
Blood in urine Hematuria
Care
Spitting of blood Hemoptysis
The bleeding is Hemorrhage is Concerning Concept Suggested Terms to
stopped controlled to be Charted be Used
Bleeding Gross Wash face and hands, Early A.M. care
blood/hemorrhage oral hygiene
Bath, alcohol Routine A.M. care
backrub, bedpan, oral
Breath hygiene
Concerning Concept Suggested Terms to Wash hands, face and P.M. care
to be Charted be Used back
Unpleasant Halitosis Special attention or Special care to
Foul Fetid treatment of mouth mouth and back
With sweet fruit like Fruity, sweet or back as ordered by
odor the doctor
Smells like alcohol Alcoholic
Consciousness
Blood Pressure Concerning Concept Suggested Terms to
Concerning Concept Suggested Terms to to be Charted be Used
to be Charted be Used Fully conscious, aware Alert, fully conscious
High Blood Pressure Hypertensive of surroundings
Low Blood Pressure Hpotensive Only partly conscious Time conscious
Unconscious, but can Stuporous
be aroused
Breathing Unconscious, cannot Comatose
be aroused
Concerning Concept Suggested Terms to
Unawareness of time Disoriented
to be Charted be Used
and place
Act of breathing Respiration
Act of inhaling Inspiration
Act of exhaling Expiration
Difficulty in breathing Dsypnea
Short period of Apnea
breathing cessation
Inability to breath in Orthopnea
supine position
Normal breathing Eupnea
Rapid breathing Hyperpnea
Increasing dyspnea Cheyne-stokes Cough
 Concerning Concept Suggested Terms to transient, constant,
to be Charted be Used shifting, sheathing,
Coughs all the time Continuous cough colicky, persistent,
Coughing over long Persistent cough deep
periods of time
Cough out materials Productive cough
Wounds
Occurring in spasms Spasmic
to describe a cough Concerning Concept Suggested Terms to
from the lungs to be Charted be Used
Cough does not Non-productive Deep Deep
produce materials cough Slight, surface only Superficial
Cough quite often Frequent cough Not infected Clean
Other self- Tight, loose, deep, Discharging pus Suppurating
explanatory terms dry, hacking, painful, Infected Infected
used rasping, exhaustive, Torn Lacerated
rash

Gait
Concerning Concept Suggested Terms to
to be Charted be Used
Dragging loosely Paralytic
Duck-like walk Waddling
Unsteady, shaky Tottering
Walk dizzily, as in Staggering, reeling
alcoholic
Strike foot forcibly Stamping
downward

Pain
Concerning Concept Suggested Terms to
to be Charted be Used
Great pain Severe
Little pain Slight
Comes in seizures Paroxysmal,
spasmodic
Spread in distant Radiating
areas
Started all at once Sudden onset
Hurt worst when Increased by moving
moving
Other descriptive Sharp, sudden,
terms darting, gnawing,
burning, stabbing,
cramping, localized,
superficial, agonizing,