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Abbreviation List for Medical Record Documentation

Medical abbreviations are a common language used by healthcare professionals to communicate efficiently in medical records. The following is a comprehensive list of abbreviations commonly used in medical record documentation across various medical specialties.

Important: While these abbreviations are widely recognized in medical practice, always be mindful of institutional policies regarding abbreviation use to ensure patient safety and accurate documentation.

General Medical Terminology

Abbreviation Full Term Meaning
ABG Arterial Blood Gas Test that measures oxygen and carbon dioxide levels in blood
ADL Activities of Daily Living Basic self-care tasks (bathing, dressing, eating, etc.)
BP Blood Pressure Pressure of blood in arteries
CBC Complete Blood Count Blood test measuring various components
CHF Congestive Heart Failure Heart condition causing fluid buildup
CNS Central Nervous System Brain and spinal cord
CPR Cardiopulmonary Resuscitation Emergency procedure for cardiac arrest
CT Computed Tomography Imaging technique using X-rays
CVA Cerebrovascular Accident Stroke
DNR Do Not Resuscitate Medical order to withhold CPR
ECG/EKG Electrocardiogram Recording of heart's electrical activity
ER/ED Emergency Room/Emergency Department Hospital department for emergency care
H&P History and Physical Patient's medical history and physical examination
ICU Intensive Care Unit Hospital department for critically ill patients
IV Intravenous Within a vein
LOS Length of Stay Duration of hospitalization
MRI Magnetic Resonance Imaging Imaging technique using magnetic fields
NP Nurse Practitioner Advanced practice registered nurse
NPO Nothing by Mouth No food or liquids orally
PA Physician Assistant Healthcare professional practicing medicine
PO Per Oral By mouth
PRN Pro Re Nata As needed
STAT Immediately Urgent action required
p.r.n. pro re nata As needed
TLC Tender Loving Care Compassionate medical care
URI Upper Respiratory Infection Infection of nose, throat, or upper airways
UTI Urinary Tract Infection Infection in urinary system

Cardiovascular System

Abbreviation Full Term Meaning
AFib/Af Atrial Fibrillation Irregular and often rapid heart rate
ASD Atrial Septal Defect Hole in the wall between heart's upper chambers
AV Atrioventricular Pertaining to atrium and ventricle
BMI Body Mass Index Measure of body fat based on height and weight
CABG Coronary Artery Bypass Graft Surgery to improve blood flow to heart
CCP Chest Compressions Manual pumping of chest during CPR
CHD Coronary Heart Disease Narrowing or blockage of coronary arteries
CK-MB Creatine Kinase-MB Enzyme indicating heart muscle damage
COPD Chronic Obstructive Pulmonary Disease Group of lung diseases causing breathing difficulties
DOE Dyspnea on Exertion Shortness of breath during physical activity
ECHO Echocardiogram Ultrasound of the heart
EF Ejection Fraction Measurement of heart's pumping efficiency
HTN Hypertension High blood pressure
MI Myocardial Infarction Heart attack
MI Myocardial Infarction Heart attack
PT/PTT Prothrombin Time/Partial Thromboplastin Time Blood clotting tests
PVD Peripheral Vascular Disease Blood circulation disorder
SQ Subcutaneous Under the skin
TIA Transient Ischemic Attack Mini stroke

Endocrine System

Abbreviation Full Term Meaning
BMR Basal Metabolic Rate Rate of energy expenditure at rest
DM Diabetes Mellitus Group of diseases affecting blood sugar
DNR Diabetes Non-Renal Diabetes without kidney complications
FBS Fasting Blood Sugar Blood glucose after fasting
HDL High-Density Lipoprotein "Good" cholesterol
HRT Hormone Replacement Therapy Treatment to replace hormones
IGT Impaired Glucose Tolerance Pre-diabetic condition
LDL Low-Density Lipoprotein "Bad" cholesterol
TSH Thyroid Stimulating Hormone Hormone regulating thyroid function
T1DM Type 1 Diabetes Mellitus Autoimmune form of diabetes
T2DM Type 2 Diabetes Mellitus Insulin resistance diabetes
THS Thyroid Hormone Hormones produced by thyroid gland

Gastrointestinal System

Abbreviation Full Term Meaning
BM Bowel Movement Act of defecation
BS Bowel Sounds Noises made by intestines
Dx Diagnosis Identification of disease
EGD Esophagogastroduodenoscopy Examination of upper digestive tract
EGD Esophagogastroduodenoscopy Examination of upper digestive tract
FBS Fecal Blood Stool Test for blood in stool
FR Failure to Respond Lack of improvement despite treatment
GERD Gastroesophageal Reflux Disease Chronic acid reflux
HCV Hepatitis C Virus Viral infection causing liver inflammation
Hx History Patient's medical background
IBS Irritable Bowel Syndrome Disorder affecting large intestine
NGT Nasogastric Tube Tube through nose to stomach
NPO Nothing By Mouth No food or liquids orally
PEG Percutaneous Endoscopic Gastrostomy Feeding tube placed through abdomen
TPN Total Parenteral Nutrition Intravenous feeding
UGI Upper Gastrointestinal Pertaining to upper digestive tract

Neurological System

Abbreviation Full Term Meaning
AD Alzheimer's Disease Progressive brain disorder
ALS Amyotrophic Lateral Sclerosis Lou Gehrig's disease
Ca Cancer Malignant disease
CASE Computed Axial Tomography Scan Imaging technique using X-rays
CNS Central Nervous System Brain and spinal cord
CSF Cerebrospinal Fluid Fluid surrounding brain and spinal cord
EEG Electroencephalogram Recording of brain electrical activity
EMG Electromyogram Recording of muscle electrical activity
GCS Glasgow Coma Scale Scale to assess consciousness level
H/A Headache Pain in the head
Hx History Patient's medical background
ICP Intracranial Pressure Pressure inside the skull
MCA Middle Cerebral Artery Major blood vessel in the brain
MS Multiple Sclerosis Autoimmune disease affecting nerves
PNS Peripheral Nervous System Nerves outside brain and spinal cord
PD Parkinson's Disease Progressive nervous system disorder
SAH Subarachnoid Hemorrhage Bleeding into space surrounding brain
TIA Transient Ischemic Attack Temporary disruption of blood flow to brain

Musculoskeletal System

Abbreviation Full Term Meaning
AK Above Knee Amputation level above knee
BKA Below Knee Amputation Surgical removal of leg below knee
C-spine Cervical Spine Neck vertebrae
CT Computed Tomography Imaging technique using X-rays
D/C Discontinue Stop a medication or treatment
DJD Degenerative Joint Disease Arthritis causing joint pain
DTR Deep Tendon Reflexes Autonomic responses to tendon stimulation
Fx Fracture Broken bone
Hx History Patient's medical background
L-spine Lumbar Spine Lower back vertebrae
OA Osteoarthritis Degenerative joint disease
ORIF Open Reduction Internal Fixation Surgery to fix broken bone
PT/OT Physical Therapy/Occupational Therapy Rehabilitation services
RA Rheumatoid Arthritis Autoimmune joint disease
ROM Range of Motion Extent of movement in joints
T-spine Thoracic Spine Mid-back vertebrae
TKR Total Knee Replacement Surgery to replace knee joint
THA Total Hip Arthroplasty Hip replacement surgery

Respiratory System

Abbreviation Full Term Meaning
ABG Arterial Blood Gas Test measuring oxygen and carbon dioxide in blood
BPAP Bilevel Positive Airway Pressure Respiratory support device
COPD Chronic Obstructive Pulmonary Disease Lung disease causing breathing problems
CPAP Continuous Positive Airway Pressure Treatment for sleep apnea
CT Computed Tomography Imaging technique using X-rays
CXR Chest X-Ray X-ray of chest area
DNR Do Not Resuscitate Order to withhold CPR
DOE Dyspnea on Exertion Shortness of breath during activity
ETT Endotracheal Tube Breathing tube
Hx History Patient's medical background
IRDS Infant Respiratory Distress Syndrome Breathing disorder in newborns
PFTs Pulmonary Function Tests Tests measuring lung function
SOB Shortness of Breath Dyspnea
SpO2 Oxygen Saturation Percentage of oxygen in blood
V/Q Ventilation/Perfusion Relationship between breathing and blood flow

Renal/Urinary System

Abbreviation Full Term Meaning
AKI Acute Kidney Injury Sudden kidney damage
AVF Arteriovenous Fistula Connection between artery and vein
BUN Blood Urea Nitrogen Kidney function test indicator
CABG Coronary Artery Bypass Graft Heart surgery for blocked arteries
CRF Chronic Renal Failure Long-term kidney failure
CXR Chest X-Ray X-ray of chest area
CKD Chronic Kidney Disease Long-term kidney damage
Cysto Cystoscopy Examination of bladder
Dial Dialysis Kidney function replacement
ESRD End-Stage Renal Disease Advanced kidney failure
F/U Follow-up Subsequent visit or appointment
Hx History Patient's medical background
KUB Kidney, Ureter, Bladder X-ray of urinary system
PD Peritoneal Dialysis Home dialysis method
TURP Transurethral Resection of Prostate Prostate surgery
UTI Urinary Tract Infection Infection of urinary system

Dosage Forms & Administration

Abbreviation Full Term Meaning
AC Before Meals Medication taken before eating
AD Right Ear Medication applied to right ear
AS Left Ear Medication applied to left ear
AU Both Ears Medication applied to both ears
BID Twice Daily Medication taken two times per day
Cap Capsule Medication form in a shell
DC Discontinue Stop medication
gtt Drops Liquid medication drops
IM Intramuscular Injected into muscle
IV Intravenous Injected into vein
IVP Intravenous Push Rapid medication injection
NS Normal Saline Sodium chloride solution
OD Right Eye Medication applied to right eye
OS Left Eye Medication applied to left eye
OU Both Eyes Medication applied to both eyes
PC After Meals Medication taken after eating
PO By Mouth Oral medication
PRN As Needed Medication taken when required
QD Once Daily Medication taken one time per day
QHS Before Bedtime Medication taken at night
QID Four Times Daily Medication taken four times per day
SL Sublingual Under the tongue
SQ/SubQ Subcutaneous Under the skin
stat Immediately Medication given right away
TID Three Times Daily Medication taken three times per day
Tab Tablet Medication in solid form

Important Safety Note: Some abbreviations may have multiple meanings depending on context. Always verify the intended meaning in each clinical situation. Many healthcare institutions maintain "Do Not Use" abbreviation lists to prevent medication errors.

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