Charting Help, Abbreviations and Acronyms

A short list of common abbreviations, acronyms, and medical terminology is used for many conditions to communicate in and outside the hospital.

…Also check out Good Charting Tips  and common charting mistakes at the bottom

Medical Acronyms

  • ALL: Acute lymphoblastic leukemia.
  • AMI: Acute myocardial infarction (heart attack)
  • B-ALL: B-cell acute lymphoblastic leukemia
  • FSH: Follicle-stimulating hormone. A blood test for follicle-stimulating hormone is used to evaluate fertility in women.
  • HAPE: High altitude pulmonary edema
  • HPS: Hantavirus pulmonary syndrome. A type of contagious, infectious disease is transmitted by rats infected with the virus.
  • IBS: Irritable bowel syndrome (A medical disease that involves the gastrointestinal tract.)
  • IDDM: Insulin-dependent diabetes mellitus. Type 1 diabetes. or DM
  • MDS: Myelodysplastic syndrome
  • NBCCS: Nevoid basal cell carcinoma syndrome
  • PE: Pulmonary embolism. A type of blood clot in the lungs.
  • SIDS: Sudden infant death syndrome
  • TSH: Thyroid-stimulating hormone. A blood test for TSH is used to diagnose thyroid disease.

Use this list as a resource for common abbreviations and acronyms used in the health care community, to quickly search and answer your questions about those letters and numbers or other notes from professionals.

Health Abbreviations

A – Medical abbreviations

  • a.c.: Before meals. As in taking medicine before meals.
  • a/g ratio: Albumin to globulin ratio.
  • ACL: Anterior cruciate ligament. ACL injuries are one of the most common ligament injuries to the knee. The ACL can be sprained or completely torn from trauma and/or degeneration.
  • Ad lib: At liberty. For example, a patient may be permitted to move out of bed freely and orders would, therefore, be for activities to be ad lib.
  • AFR: Acute renal failure
  • ADHD: Attention deficit hyperactivity disorder
  • ADR: Adverse drug reaction. If a patient is taking a prescription drug to treat high blood pressure disease
  • AIDS: Acquired immune deficiency syndrome
  • AKA: Above the knee amputation.
  • Anuric: Not producing urine. A person who is anuric is often critical and may require dialysis.
  • ANED: Alive no evidence of disease. The patient arrived in the ER alive with no evidence of disease.
  • ADH: Antidiuretic hormone
  • ARDS: Acute respiratory distress syndrome.
  • ARF: Acute renal (kidney) failure
  • ASCVD: Atherosclerotic cardiovascular disease. A form of heart disease.

B – Medical abbreviations

  • b.i.d.: Twice daily. As in taking medicine twice daily.
  • bld: Blood. Blood was visible on the patient’s scalp.
  • Bandemia: Slang for an elevated level of band forms of white blood cells.
  • Bibasilar: At the bases of both lungs. For example, someone with a pneumonia in both lungs might have abnormal bibasilar breath sounds.
  • BKA: Below the knee amputation.
  • BMP: Basic metabolic panel. Electrolytes (potassium, sodium, carbon dioxide, and chloride) and creatinine and glucose.
  • BP: Blood pressure. Blood pressure is recorded as part of the physical examination. It is one of the “vital signs.”
  • BPD: Borderline personality disorder. A personality disorder.
  • BSO: Bilateral salpingo-oophorectomy. A BSO is the removal of both of the ovaries and adjacent Fallopian tubes and often is performed as part of a total abdominal hysterectomy.

C – Medical abbreviations

  • C&S: Culture and sensitivity, performed to detect infection.
  • C/O: Complaint of. The patient’s expressed concern.
  • cap: Capsule.
  • Ca: Cancer; carcinoma. For example, a patient who undergoing treatment for cancer should assure that they are eating and drinking enough fluids daily, both during and after treatment.
  • CABG. Coronary artery bypass graft. A surgery involving the heart.
  • CBC: Complete blood count.
  • CC: Chief complaint. The patient’s main concern.
  • CDE: Complete dental (oral) evaluation.
  • cc: Cubic centimeters. For example, the amount of fluid removed from the body is recorded in ccs.
  • Chem panel: Chemistry panel. A comprehensive screening blood test that indicates the status of the liver, kidneys, and electrolytes.
  • CPAP: Continuous positive airway pressure. A treatment for sleep apnea.
  • COPD: Chronic obstructive pulmonary disease.
  • CT: Chemotherapy. A type of treatment therapy for cancer.
  • CVA: Cerebrovascular accident (Stroke).

D – Medical abbreviations

  • D/C or DC: Discontinue or discharge. For example, a doctor will D/C a drug. Alternatively, the doctor might DC a patient from the hospital.
  • DCIS: Ductal Carcinoma In Situ. A type of breast cancer. The patient is receiving treatment for Ductal Carcinoma In Situ.
  • DDX: Differential diagnosis. A variety diagnostic possibilities are being considered to diagnose the type of cancer present in the patient.
  • DJD: Degenerative joint disease. Another term for osteoarthritis.
  • DM: Diabetes mellitus.
  • DNC, D&C, or D and C: Dilation and curettage. Widening the cervix and scrapping with a curette for the purpose of removing tissue lining the inner surface of the womb (uterus).
  • DNR: Do not resuscitate. This is a specific order not to revive a patient artificially if they succumb to illness. If a patient is given a DNR order, they are not resuscitated if they are near death and no code blue is called.
  • DOE: Dyspnea on exertion. Shortness of breath with activity.
  • DTR: Deep tendon reflexes. These are reflexes that the doctor tests by banging on the tendons with a rubber hammer.
  • DVT: Deep venous thrombosis (blood clot in large vein).

E – Medical abbreviations

  • ETOH: Alcohol. ETOH intake history is often recorded as part of a patient history.
  • ECT: Electroconclusive therapy. A procedure used to control seizures (convulsions).

F – Medical abbreviations

  • FX: Fracture.

G – Medical abbreviations

  • g: gram, a unit of weight. The cream is available in both 30 and 60 gram tubes.
  • GvHD: Graft vs. host disease. It is complicated by the syndromes of acute and chronic graft-vs-host
  • disease (GVHD).
  • gtt: Drops.

H – Medical abbreviations

  • H&H: Hemoglobin and hematocrit. When the H & H is low, anemia is present. The H&H can be elevated in persons who have lung disease from long-term smoking or from disease, such as polycythemia rubra vera.
  • H&P: History and physical examination.
  • h.s.: At bedtime. As in taking a medicine at bedtime.
  • H/O or h/o: History of. A past event that occurred.
  • HA: Headache.
  • HRT: Hormone replacement or hormone replacement therapy.
  • HTN: Hypertension.

I – Medical abbreviations

  • I&D: Incision and drainage.
  • IBD: Inflammatory bowel disease. A name for two disorders of the gastrointestinal (BI) tract,
  • Crohn’s disease and ulcerative colitis
  • ICD: Implantable cardioverter defibrillator
  • ICU: Intensive care unit. The patient was moved to the intensive care unit.
  • IM: Intramuscular. This is a typical notation when noting or ordering an injection (shot) given into muscle, such as with B12 for pernicious anemia.
  • IMP: Impression. This is the summary conclusion of the patient’s condition by the healthcare professional at that particular date and time.
  • ITU: Intensive therapy unit
  • in vitro: In the laboratory
  • in vivo: In the body
  • IPF: Idiopathic pulmonary fibrosis. A type of lung disease.
  • IU: International units.

J – Medical abbreviations

  • JT: Joint.

K – Medical abbreviations

  • K: Potassium. An essential electrolyte frequently monitored regularly in intensive care.
  • KCL: Potassium chloride.

L – Medical abbreviations

  • LCIS: Lobular Carcinoma In Situ. A type of cancer of the breast. The patient is receiving treatment for Lobular Carcinoma In Situ.
  • LBP: Low back pain. LBP is one of most common medical complaints.
  • LLQ: Left lower quadrant. Diverticulitis pain is often in the LLQ of the abdomen.
  • LUQ: Left upper quadrant. The spleen is located in the LUQ of the abdomen.
  • Lytes: Electrolytes (potassium, sodium, carbon dioxide, and chloride).

M – Medical abbreviations

  • MCL: Medial collateral ligament
  • mg: Milligrams
  • M/H: Medical history
  • ml: Milliliters
  • MVP: Mitral valve prolapse

N – Medical abbreviations

  • N/V: Nausea or vomiting.
  • Na: Sodium. An essential electrolyte is frequently monitored regularly in intensive care.
  • NCP: Nursing care plan
  • NPO: Nothing by mouth. For example, if a patient was about to undergo a surgical operation requiring general anesthesia, they may be required to avoid food or beverage prior to the procedure.
  • NSR: Normal sinus rhythm of the heart

O – Medical abbreviations

  • O&P: Ova and parasites. Stool O & P is tested in the laboratory to detect parasitic infection in persons with chronic diarrhea.
  • O.D.: Right eye.
  • O.S.: Left eye.
  • O.U.: Both eyes.
  • ORIF: Open reduction and internal fixation, such as with the orthopedic repair of a hip fracture.

P – Medical abbreviations

  • P: Pulse. Pulse is recorded as part of the physical examination. It is one of the “vital signs.”
  • p: After meals. As in take two tablets after meals.
  • p.o.: By mouth. From the Latin terminology per os.
  • p.r.n.: As needed. So that it is not always done, but done only when the situation calls for it (or example, taking a pain medication only when having pain and not without pain).
  • PCL: Posterior cruciate ligament.
  • PD: Progressive disease. Patients at risk of developing progressive disease of the kidneys include those with proteinuria or hematuria.
  • PERRLA: Pupils equal, round, and reactive to light and accommodation.
  • PFT: Pulmonary function test. A test to evaluate the how well the lungs are functioning.
  • PERRLA: Pupils equal, round, and reactive to light and accommodation.
  • Plt: Platelets, one of the blood forming elements along with the white and red blood cells.
  • PMI: Point of maximum impulse of the heart when felt during examination, as in beats against the chest.
  • PMS: Premenstrual syndrome
  • PT: Physical therapy
  • PTH: Parathyroid hormone
  • PTSD: Post-traumatic stress syndrome
  • PUD: Peptic ulcer disease. A type of ulcer of the stomach.

Q – Medical abbreviations

  • q.d.: Each day. As in taking a medicine daily.
  • q.i.d.: Four times daily. As in taking a medicine four times daily.
  • q2h: Every 2 hours. As in taking a medicine every 2 hours.
  • q3h: Every 3 hours. As in taking a medicine every 3 hours.
  • qAM: Each morning. As in taking a medicine each morning.
  • qhs: At each bedtime. As in taking a medicine each bedtime.
  • qod: Every other day. As in taking a medicine every other day.
  • qPM: Each evening. As in taking a medicine each evening.

R – Medical abbreviations

  • RA: Rheumatoid arthritis. A type of joint disease.
  • RDS: Respiratory distress syndrome
  • R/O: Rule out. Doctors frequently will rule out various possible diagnoses when figuring out the correct diagnosis.
  • REB: Rebound, as in rebound tenderness of the abdomen when pushed in and then released.
  • RLQ: Right lower quadrant. The appendix is located in the RLQ of the abdomen.
  • ROS: Review of systems. An overall review concerns relating to the organ systems, such as the respiratory, cardiovascular, and neurologic systems.
  • RUQ: Right upper quadrant. The liver is located in the RUQ of the abdomen.

S – Medical abbreviations

  • s/p: Status post. For example, a person who had a knee operation would be s/p a knee operation.
  • SAD: Season affective disorder. A type of depression that occurs during the winter months when there is little light.
  • SOB: Shortness of breath.
  • SQ: Subcutaneous. This is a typical notation when noting or ordering an injection (shot) given into the fatty tissue under the skin, such as with insulin for diabetes mellitus.

T – Medical abbreviations

  • T: Temperature. Temperature is recorded as part of the physical examination. It is one of the “vital signs.”
  • T&A: Tonsillectomy and adenoidectomy
  • t.i.d.: Three times daily. As in taking a medicine three times daily.
  • tab: Tablet
  • TAH: Total abdominal hysterectomy. A type of surgery to remove a woman’s uterus, Fallopian tubes, and ovaries.
  • THR: Total hip replacement
  • TKR: Total knee replacement
  • TMJ: Tempomandibular joint

U – Medical abbreviations

  • UA or u/a: Urinalysis. A UA is a typical part of a comprehensive physical examination.
  • U or u**: Unit. Mistaken as the number 0 or 4, causing a 10-fold overdose or greater (for example, 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so the dose is given in volume instead of units (for example, 4u seen as 4cc).
  • ULN: Upper limits of normal
  • URI: Upper respiratory infection, such as sinusitis or the common cold
    ut dict: As directed. As in taking a medicine according to the instructions that the health care professional gave in the office or in the past
  • UTI: Urinary tract infection

V – Medical abbreviations

  • VSS: Vital signs are stable. This notation means that from the standpoint of the temperature, blood pressure, and pulse, the patient is doing well.

W – Medical abbreviations

  • Wt: Weight. Bodyweight is often recorded as part of the physical examination.

X – Medical abbreviations

  • XRT: Radiotherapy (external). A type of treatment that uses radiation.

–Medicine Net

Tapers Online: additional medical abbreviations

Common Charting Mistakes

1. Failing to record pertinent health or drug information: Suppose the patient has an allergy or a disease (such as diabetes, hemophilia, or glaucoma) that his caregivers need to know about. But you forget to record that on his chart. You could end up in court, as did a nurse at a large metropolitan hospital.

The nurse neglected to record her patient’s penicillin allergy in the admission notes. Because the intern didn’t know the patient was penicillin-allergic, he gave the patient a penicillin injection. The patient, who was incoherent and couldn’t tell the intern about the allergy, went into anaphylactic shock and suffered irreversible brain damage. At the trial, the court found the nurse guilty of negligence.

So you make sure you ask about every patient’s food and drug allergies, diseases, and chronic health problems. And record the information on the admission sheet and in the nurses’ notes. Alert other staff members to drug allergies by putting a bright label on the outside of the patient’s chart, according to hospital policy.

2. Failing to record nursing actions: Record everything you do for a patient on his chart as soon as possible. Let’s say the day nurse observes heavy drainage from a surgical wound and changes the patient’s dressing. But she forgets to record the dressing change and her assessment of heavy drainage before she leaves.

The evening nurse also notices heavy drainage from the wound. She checks the nurses’ notes and finds no evidence that the dressing was changed. She considers the amount of drainage normal for a period of several hours. She changes the dressing but, like the day nurse, forgets to chart her action.

The night nurse does the same. Is the condition getting more serious? Is the patient’s life in jeopardy? No one knows because no one realizes that the patient’s wound is seeping more than it should.

The usual excuse for not charting is “not enough time.” Consider flow sheets that you can insert in the patient’s chart at the end of the shift. If your hospital has standard flow sheets, use them. If it doesn’t, ask for them.

3. Failing to record that medications have been given: Record every medication you give when it’s given–including the dose, route, and time. A day nurse gave a patient heparin by intravenous push just before she went off duty. An hour later, the evening nurse saw the order for heparin–but no indication that it had been given. So she gave the patient the same dose. The patient began to hemorrhage and went into hypovolemic shock. He recovered–then successfully sued the hospital.

Both nurses made mistakes here. The first should have recorded that she’s given the dose. The second should have been suspicious when she saw the order for heparin but no evidence that it had been given. She could have:

  • Asked the patient if he’d received the medication
  • Called the pharmacy to see if the dose had already been furnished
  • Called the first nurse at home

So always investigate when you suspect a medication may have been given but not recorded.

4. Recording on the wrong chart: You can’t be too careful in any situation that might lead to confusion between two patients: same last name, same room, same condition, or same doctor. Mrs. B. Moyer and Mrs. C. Moyer were on the same unit. Mrs. B. Moyer was being treated for severe hypertension; Mrs. C. Moyer, was for acute thrombophlebitis. Mrs. C. Moyer’s doctor ordered 4,000 units of heparin for her.

The nurse mistakenly transcribed the heparin order onto Mrs. B. Moyer’s chart and administered the heparin. Mrs. B. Moyer started bleeding.

When you have two or more patients with the same name, be sure a different nurse is assigned to each patient; develop a system of flagging the patients’ names on charts and medication records. And check wristbands before you give medications.

5. Failing to document a discontinued medication: If the patient is supposed to be taken off medication because of its adverse effects, you need to document that order promptly.

A doctor suspected that his patient, who was taking high doses of aspirin for arthritis, had developed an ulcer. So he discontinued the medication. But the patient’s nurse forgot to record the order on the medication sheet, and she and the other nurses continued giving aspirin. The ulcer bled, and the patient eventually underwent a partial gastrectomy because her condition deteriorated. She sued the hospital for the nurses’ negligence and won.

Cross-checking the doctor’s orders and the medication sheet before giving the medication would have prevented this patient’s serious complications.

6. Failing to record drug reactions or changes in the patient’s condition: Monitoring a patient’s response to treatment isn’t enough. You need to recognize an adverse reaction or a worsening of the patient’s condition, then intervene before the patient is seriously harmed.

A patient complained of nausea, dizziness, abdominal pain, and itchy skin shortly after receiving his first 100-mg dose of nitrofurantoin macrocrystals (Macrodantin). His nurse wasn’t concerned, though. By evening, after two more doses of the medication, he was vomiting and had a high fever, urticaria, and early symptoms of shock. He sued his nurse for negligence.

The fact that most patients don’t have adverse reactions to certain drugs shouldn’t lull you into carelessness; most drugs can cause problems in some patients who take them. So observe your patients closely, consider the possibility of adverse reactions when a patient reports new symptoms, and follow up appropriately.

7. Transcribing orders improperly or transcribing improper orders: If you transcribe orders on the wrong chart or transcribe the wrong dose, you can be held liable for any resulting injury. You can also be held liable if you transcribe or carry out an order as it’s written if you know or suspect the order is wrong. And you should be familiar enough with the medications, procedures, and activities you’re responsible for to know when something isn’t right.

A doctor ordered 5 ml of atropine for a patient on the coronary care unit. He meant to order 0.5 ml, but he didn’t include the zero or write the decimal point clearly. The nurse transcribed the order as 5 ml, although she didn’t think it seemed right. She decided the doctor knew best and didn’t check the dose before recording it.

Anytime you’re unsure about a drug order, check it with the prescribing doctor. And if you’re sure the order is wrong, tell the doctor why you can’t administer the drug, then notify your nurse-manager. She’ll probably talk with the doctor and tell him that he’ll have to give the drug himself.

8. Writing illegible or incomplete records: These mistakes rarely cause lawsuits. But they can rear their ugly heads in the midst of lawsuits. Imagine your embarrassment at being called to testify and not being able to read your own handwriting or having to admit that the information recorded is incomplete.

To play it safe, remember each of these good charting practices:

  • Print if your handwriting is difficult to read.
  • Sign your full name and title somewhere on every page where you’ve charted.
  • Don’t leave blank spaces, lines, or boxes on charts. If you don’t use the space, draw a line through it or write N/A (not applicable).
  • Don’t use abbreviations that aren’t on the hospital’s approved list of abbreviations. Chances are someone could misunderstand your abbreviation. And years later, you may not even remember what it meant.
  • Record every nursing action as soon as possible after you’ve finished it.
  • Write enough to convince a reader that the patient was adequately cared for.

Such careful attention to charting is never a waste of time. It helps you demonstrate the good care you’ve given, saving yourself the need to defend it in court someday.

 -Nurse Service Organization

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