A AMA against medical advice

A.A.R.O.M. active assistive range of motion A&O alert and oriented

AAC augmentative and alternative communication A/P anterior–posterior

A.B.G arterial blood gas A.R.O.M. active range of motion

a.c. before meals ASAP as soon as possible

A/C assist control ASD autism spectrum disorder

ADA Diet American Diabetes Association Diet ASL American Sign Language

A.D.L. activities of daily living B

A.Fib. atrial fibrillation b.i.d. twice a day

AKA above-knee amputation or above-the-knee amputation

BKA below-knee amputation

ALS amyotrophic lateral sclerosis B/L bilateral

B.L.BS bilateral breath sounds C1, C2, etc. first cervical vertebrae, second cervical vertebrae, etc.

BMR basal metabolism rate CA cardiac arrest

BP blood pressure CA, ca cancer, carcinoma

BR bed rest CABG coronary artery bypass graft

bs bowel sounds CAD coronary artery disease

BS breath sounds cal calorie

B/S bedside cath catheter

bx biopsy CBC complete blood count

C cc cubic centimeter

c̅ with CC chief complaint

C Celsius, centigrade CHF congestive heart failure, chronic heart failure

CCU coronary care unit CP cerebral palsy

CHI closed head injury CPAP continuous positive airway pressure

cm centimeter CPR cardiopulmonary resuscitation

CMT continuing medication and treatment CRF chronic renal failure

CN cranial nerve CRNP certified registered nurse practitioner

CNA certified nursing assistant CSF cerebrospinal fluid

CNS central nervous system CT computerized tomography

c/o complains of CV cardiovascular

COTA certified occupational therapy assistant CVA cerebral vascular accident

cont continue(d) CXR chest X-ray

COPD chronic obstructive pulmonary disease D

d day d/t due to

d/c discontinue Dx diagnosis

DC discharge E

DM diabetes mellitus ECC, EKG electrocardiogram

DNK do not know ED emergency department

DNKA did not keep appointment EEG electroencephalogram

DNR do not resuscitate EENT eyes, ears, nose, throat

DNT did not test EMG electromyogram

DOA dead on arrival ENT ears, nose, throat

DOB date of birth ER emergency room

DOE dyspnea on exertion ETOH ethanol (alcohol)

exam examination G

ext external, exterior GB gall bladder

F GCS Glasgow Coma Scale

F Fahrenheit GE gastroenterology

FH family history GERD gastroesophageal reflux disease

fib fibrillation G/E gastroenteritis

fl, fld fluid gen general

FOB foot of bed gest. gestation

f/u follow-up G.I. gastrointestinal

FWB full weight bearing GNA geriatric nursing assistant

Fx fracture gluc glucose

GP general practitioner, general paralysis HBP high blood pressure

GSW gunshot wound h.d. at bedtime

GTT glucose tolerance test HEENT head, eyes, ears, nose, throat

Gt. tr. gait training HEP home exercise program

GYN gynecology H2O water

H h/o history of

h hour HOB head of bed

H/A headache H&P history and physical

HAV hepatitis A virus HR heart rate

Hb. hemoglobin HTN hypertension

HB heart block HVD hypertensive vascular disease

Hx history I&O intake and output

Hz hertz (cycles/second) IPPB intermittent positive pressure breathing

I irreg. irregular

ICCU intensive coronary care unit IV intravenous(ly)

ICP intracranial pressure J

ICU intensive care unit J, jt. joint

imp. impression K

incr. increased(ing) K potassium, kidney

inf infusion, inferior L

inspire inspiration, inspiratory L left, liver, liter, lower, light, lumbar

int. internal L2, L3 second lumbar vertebrae, third lumbar vertebrae

lab laboratory Lx larynx

lac. laceration L&W living and well

lat. lateral M

LBW low birth rate m, M married, male, mother, murmur, meter, mass, molar

L.E. lower extremities max. maximum, maxillary

liq. liquid MBC maximum breathing capacity

L.O.C. loss of consciousness, level of consciousness, laxative

MBSSof choice modified barium swallow study

LOS length of stay MCA middle cerebral artery

LP lumbar puncture MD muscular dystrophy

LPN licensed practical nurse mdnt. midnight

LUE left upper extremity med. medicine

mets. metastasis n. nerve

MG myasthenia gravis Na sodium

MI myocardial infarction NaCl sodium chloride

min minute NAD no abnormality detected

MICU medical intensive care unit NAD no apparent distress

mod moderate neg. negative

MRI magnetic resonance imaging neur. neurology

MRSA methicillin-resistant Staphylococcus aureus NG nasogastric

mss massage NIC neonatal intensive care

MVA motor vehicle accident NICU neonatal intensive care unit

N NKA no known allergies

no. number o none, without

NOS not otherwise specified O oral

NPO nothing by mouth O2 oxygen

NSA no specific abnormality O2 cap. oxygen capacity

NST nonstress test O2 sat. oxygen saturation

N&V nausea and vomiting OA osteoarthritis

NVD nausea, vomiting, diarrhea OB, OBG obstetrics

N&W normal and well OB/GYN obstetrics and gynecology

NWB non–weight bearing Obs observation

NYD not yet diagnosed OBS organic brain syndrome

O ODD oppositional defiant disorder

O/E on examination O.T. occupational therapy, old tuberculin

OH occupational history OR operating room

OHD organic heart disease P

oint. ointment PA physician’s assistant

O.M. otitis media p&a percussion and auscultation

O.M.E. otitis media with effusion PACU post anesthesia care unit

OOB, oob out of bed PAF paroxysmal atrial fibrillation

Op. operation palp. palpate, palpated, palpable

ot. ear Path pathology

Oto otolaryngology PA view posterior–anterior view on X-ray

OTC over-the-counter (pharmaceuticals) p/c, p.c. after meals

PD Parkinson’s disease PI present illness, pulmonary insufficiency

pdr. powder PICU pulmonary intensive care unit

PDN private duty nurse PID pelvic inflammatory disease

PE physical exam, pulmonary embolism, pressure equalizer

plts. (tubes) platelets

Ped. pediatrics P.M. afternoon, postmortem

PEEP positive end-expiratory pressure PMH past medical history

PEG percutaneous endoscopic gastrostomy PMR physical medicine and rehabilitation

PET positron emission tomography PN poorly nourished, practical nurse

PH past history P&N psychiatry and neurology

pharm pharmacy PNA pneumo, pneumonia

PHYS. physical, physiology PNI peripheral nerve injury

PNX pneuomothorax p.r.n., PRN as often as necessary, as needed

p.o. by mouth prod. productive

p.o.d. postoperative day Prog. prognosis

pos. positive PROM passive range of motion

post. posterior pron. pronator, pronation

POSTOP. postoperative prosth. prosthesis

pot. or potass. potassium PSH past surgical history

PR proctology Psych. psychiatry

pre-op preoperative pt., Pt. patient

prep. prepare for PT, P.T. physical therapy

p.r.m. according to circumstances PTA prior to admission

PTA pulse posterior tibial artery pulse quad. quadriplegic

PUD peptic ulcer disease R

PVD peripheral vascular disease R, r right

PVT previous trouble R. rub, rectal temperature

PWB% partial weight bearing with percent RA rheumatoid arthritis, right atrium

Px, PX physical examination rad. radial

Q r.a.m. rapid alternating movements

q every R.A.S. right arm sitting

q.h. every hour RAtx radiation therapy

q.i.d. four times a day rbc/RBC red blood cell, red blood count

qt. quart RCA right coronary artery

RCU respiratory care unit RN registered nurse

RD respiratory distress RND radical neck dissection

RDS respiratory distress syndrome RO, R/O rule out

RE reconditioning exercise ROM range of motion, rupture of membranes, right otitis med

reg. regular ROS review of symptoms

rehab. rehabilitation Rt. right

resp. respiratory, respirations RT radiation therapy, respiratory therapy

RF rheumatic fever RUE right upper extremity

RLAS Rancho Los Amigos Scale RV residual volume

R to L&A react to light and accommodation RW rolling walker

RLE right lower extremity Rx therapy, prescription

S sec second

s without Sens. sensory, sensation

S sensation, sensitive, serum sep. separated

Sa. saline SGA small for gestational age

s.c. subcutaneous(ly) s.gl. without correction (without glasses)

Scc squamous cell carcinoma SH social history

SCCA squamous cell carcinoma, squamous cell carcinoma

SI antigen stroke index

SCD sudden cardiac death sib. sibling

SCI spinal cord injury SICU surgical intensive care unit

schiz schizophrenia SIDS sudden infant death syndrome

SCU special care unit skel. skeletal

Sl. slightly sp&H speech and hearing

SL under the tongue spin. spine, spinal

SLP speech-language pathologist spont. spontaneous

sm small s/s signs and symptoms

SNF skilled nursing facility SS social service

SOAP subjective, objective, assessment, plan ST speech therapy

SOB shortness of breath stat., STAT immediately

S/P, s/p status post (previous condition) STD sexually transmitted disease

sp. cd. spinal cord subcut. subcutaneous

spec. specimen subling. sublingual

sp. fl. spinal fluid sup. superior

supin. supination TB tuberculosis

surg. surgery, surgical TBI traumatic brain injury

Sx symptoms temp temperature

sys. system THERAP. therapy, therapeutic

Syst. systolic THR total hip replacement

Sz seizure TIA transient ischemic attack

T TKR total knee replacement

T temperature TNM tumor, nodes, and metastases

T&A tonsils and adenoids, tonsillectomy and adenoidectomy

TO telephone order

tab. tablet TPN total parenteral nutrition

TAH total abdominal hysterectomy TPR temperature, pulse, respiration

tr trace URD upper respiratory disease

trach tracheostomy URI upper respiratory infection

tsp. teaspoon Urol. urology

Tx treatment, traction u/s, US ultrasound

U UTI urinary tract infection

U/A urinalysis V

UCD, UCHD usual childhood diseases V vein

UG upward gaze VA visual acuity

Unilat. unilateral vag vagina, vaginal

u/o under observation VC, vit.cap. vital capacity

Ur. urine VD venereal disease

vent. ventilator W/C, wh.ch. wheelchair

vert. vertical WBT weight bearing tolerance

VF visual fields, ventricular fibrillation WFL within functional limits

VFSS videofluoroscopic swallowing study w/n within

Via by way of WNL within normal limits

vit. vitamin WP whirlpool

VN visiting nurse wt. weight

VO verbal order w/u workup

VS, V.S. vital signs X

W x times

w, wk week Y
y.o. years old

yrs. years