In the healthcare industry, documentation is very important. Medical records must be written legibly and easily understood by those who access them. A record is a valuable source of data used by health care team members to facilitate communication, financial billing, assessment, research, auditing and for legal purposes. Using abbreviations in medical records shorten written narratives in patient care recording. As long as the abbreviations used are universally recognized and understood nurses can use this to make recording faster.

nursing-abbreviations-and-medical-terminologies

Every facility has its own set of approved abbreviations, symbols and acronyms. It is important to get to know your facility’s list of abbreviation to avoid confusion in documentation. Drug names should NEVER be abbreviated, with the exception of those stated in your facility’s list and medications such as ASA and vitamins. In addition, nurses should also know metric abbreviations such as mg, g, or L.

Abbreviation / Symbol Meaning
@ at
Female
Male
ā Before (ante)
aa Equal parts
A+A Alert and active
A+A+O Alert, awake and oriented
Abd Abdomen
Abr Abrasion
ABR Absolute bed rest
Abx/ABT Antibiotics
ac Before meals
ACE Angiotension converting enzyme
ACLS Advanced cardiac life support
AD Admitting diagnosis
ADH Antidiuretic hormone
A&D Admission and discharge
ADL Activities of daily living
ad lib As desired
Adm. Admission
AED Automated External Defibrillator
A-fib Atrial Fibrillation
A-flutter Atril Flutter
AH Abdominal hysterectomy
AHD Arteriosclerotic heart disease
AICD Automatic Internal Cardiac Defibrillator
AIDS Acquired immunodeficiency syndrome
AK Above the knee
AKA Above the knee amputation
ALOC Altered level of consciousness
ALS Advanced life support
A.M. or am or a.m. Morning
amb Ambulatory
AMI Acute myocardial infarction
AML Acute myeloid leukemia
amt. Amount
Ant Anterior
A-P Anteroposterior (front to back)
AP Appendectomy
APGAR Appearance, Pulse, Grimace, Activity, Respiration
Approx. Approximately
Appt. Appointment
ARF Acute renal failure
ARI Acute respiratory infection
ARDS Acute Respiratory Distress Syndrome
ASA Acetylsalicylic acid
ASAP As soon as possible
ASD Atrial septal defect
ASHD Arteriosclerotic heart disease
ATN Acute tubular necrosis
AU Both Ears
AV Atrioventricular
AVSD Atrioventricular septal defect
B&B or b&b Bowel and bladder training
BC Blood cultures
BCC Basal cell carcinoma
BCG Baccili Calmette-Guerin
BG Blood glucose
bid or BID Twice daily
Bil Bilateral
BiPAP Bi-level positive airway pressure
BK Below knee
BKA Below the knee amputation
BLE Both lower extremities
BM Bowel movement
BMI Body Mass Index
B/O Because of
BP Blood pressure
BPD Bronchopulmonary Dysplasia
BPH Benign prostatic hypertrophy
BR Bedrest
BS Blood sugar
BSA Body surface area
BUN Blood Urea Nitrogen
BVM Bag-valve-mask
BW Birth weight
Bx Biopsy
°C Celsius
ċ With
C&S Culture and sensitivity
CA Cancer, carcinoma
CAB Coronary artery bypass
CABG Coronary artery bypass graft
CAD Coronary artery disease
Cal Calories
Cap Capsule
CAPD Continuous ambulatory peritoneal dialysis
CAT or CT Computerized axial tomography
Cath Catheter, catheterize
CAVH Continuous Arteriovenous hemofiltration
CAVHD Continuous Arteriovenous haemodialysis
CBC Complete blood count
CBR Complete bed rest
cc Cubic centimeter
C/C or CC Chief complaint
CDI Clean, dry, and intact
CF Cystic Fibrosis
CGT Continuous gastrostomy tube
chemo Chemotherapy
CHF Congestive heart failure
CHI Closed head injury
CICU Cardiac (coronary) intensive care unit
CKD Chronic kidney disease
CLL Chronic lymphocytic leukaemia
cm Centimeter
CNS Central nervous system
CO2 Carbon dioxide
C/O Complains of
COPD Chronic obstructive pulmonary disease
CP Chest pain
CPAP Continuous (constant) positive airway pressure
CPR Cardiopulmonary resuscitation
CPT Chest Physical Therapy
CRF Chronic renal failure
CSF Cerebrospinal fluid
CSMT Circulation, sensation, movement, temperature
CSR Central supply room
CTA Clear to Auscultation
CV Cardiovascular
CVA Cerebrovascular accident
CVD Cardiovascular disease
CXR Chest xray
DAT diet as tolerated
DB&C Deep Breathing and coughing
DC or dc discontinue
DI Diabetes Insipidus
DIC Disseminated Intravascular Coagulopathy
DM diabetes mellitus
DNA Deoxyribonucleic Acid
DNR do not resuscitate
DOB date of birth
DOA date of admission
DOE dyspnea on exertion
DSA Digital Subtraction Angiography
DT delirium tremens
DTPA Diethylene-triamine-penta-acetic acid Scan
DVT deep vein thrombosis
DW distilled water; dry weight
Dx diagnosis
DXRT Deep X-Ray Therapy
D&V Diarrhea and vomiting
EBL Estimated blood loss
EC Enteric coated
E coli Escherichia coli
ECF Extended care facility
ECG or EKG Electrocardiogram
ECMO Extracorporeal membrane oxygenation
ECV Extracellular volume
ECW Extracellular water
ED Emergency Department
EDC Expected date of confinement
EMS Emergency Medical Services
EEG Electroencephalogram
EENT Eyes, Ears, nose, throat
EEP End expiratory pressure
EF Ejection fraction
ET or ETT Endotracheal tube
EGA Estimated gestational age
ELISA Enzyme linked immunosorbent assay (immunological testing)
EPAP Expiratory positive airway pressure
EPI Epinephrine
EPO Erythropoietin
ET Endotracheal tube
ETD Estimated time of death
°F Fahrenheit
FBS Fasting blood sugar
FF Force fluids
Fe Iron
FHR Fetal heart rate
FHx Family history
ft Foot
FTB Full-Thickness Burn
Fx Fracture

Originally posted 2014-12-11 02:41:03. Republished by Blog Post Promoter