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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 / SymbolMeaning
@at
Female
Male
āBefore (ante)
aaEqual parts
A+AAlert and active
A+A+OAlert, awake and oriented
AbdAbdomen
AbrAbrasion
ABRAbsolute bed rest
Abx/ABTAntibiotics
ac Before meals
ACEAngiotension converting enzyme
ACLSAdvanced cardiac life support
ADAdmitting diagnosis
ADHAntidiuretic hormone
A&DAdmission and discharge
ADLActivities of daily living
ad libAs desired
Adm.Admission
AEDAutomated External Defibrillator
A-fibAtrial Fibrillation
A-flutterAtril Flutter
AHAbdominal hysterectomy
AHDArteriosclerotic heart disease
AICDAutomatic Internal Cardiac Defibrillator
AIDSAcquired immunodeficiency syndrome
AKAbove the knee
AKAAbove the knee amputation
ALOCAltered level of consciousness
ALSAdvanced life support
A.M. or am or a.m.Morning
ambAmbulatory
AMIAcute myocardial infarction
AMLAcute myeloid leukemia
amt. Amount
AntAnterior
A-PAnteroposterior (front to back)
APAppendectomy
APGARAppearance, Pulse, Grimace, Activity, Respiration
Approx.Approximately
Appt.Appointment
ARFAcute renal failure
ARIAcute respiratory infection
ARDSAcute Respiratory Distress Syndrome
ASAAcetylsalicylic acid
ASAPAs soon as possible
ASDAtrial septal defect
ASHDArteriosclerotic heart disease
ATNAcute tubular necrosis
AUBoth Ears
AVAtrioventricular
AVSDAtrioventricular septal defect
B&B or b&bBowel and bladder training
BCBlood cultures
BCCBasal cell carcinoma
BCGBaccili Calmette-Guerin
BGBlood glucose
bid or BIDTwice daily
BilBilateral
BiPAPBi-level positive airway pressure
BKBelow knee
BKABelow the knee amputation
BLEBoth lower extremities
BMBowel movement
BMIBody Mass Index
B/OBecause of
BPBlood pressure
BPDBronchopulmonary Dysplasia
BPHBenign prostatic hypertrophy
BRBedrest
BSBlood sugar
BSABody surface area
BUNBlood Urea Nitrogen
BVMBag-valve-mask
BWBirth weight
BxBiopsy
°CCelsius
ċWith
C&SCulture and sensitivity
CACancer, carcinoma
CABCoronary artery bypass
CABGCoronary artery bypass graft
CADCoronary artery disease
CalCalories
CapCapsule
CAPDContinuous ambulatory peritoneal dialysis
CAT or CTComputerized axial tomography
CathCatheter, catheterize
CAVHContinuous Arteriovenous hemofiltration
CAVHDContinuous Arteriovenous haemodialysis
CBCComplete blood count
CBRComplete bed rest
ccCubic centimeter
C/C or CCChief complaint
CDIClean, dry, and intact
CFCystic Fibrosis
CGTContinuous gastrostomy tube
chemoChemotherapy
CHFCongestive heart failure
CHIClosed head injury
CICUCardiac (coronary) intensive care unit
CKDChronic kidney disease
CLLChronic lymphocytic leukaemia
cm Centimeter
CNSCentral nervous system
CO2Carbon dioxide
C/OComplains of
COPDChronic obstructive pulmonary disease
CPChest pain
CPAPContinuous (constant) positive airway pressure
CPRCardiopulmonary resuscitation
CPTChest Physical Therapy
CRFChronic renal failure
CSFCerebrospinal fluid
CSMTCirculation, sensation, movement, temperature
CSRCentral supply room
CTAClear to Auscultation
CVCardiovascular
CVACerebrovascular accident
CVDCardiovascular disease
CXRChest xray
DATdiet as tolerated
DB&CDeep Breathing and coughing
DC or dcdiscontinue
DIDiabetes Insipidus
DICDisseminated Intravascular Coagulopathy
DMdiabetes mellitus
DNADeoxyribonucleic Acid
DNRdo not resuscitate
DOBdate of birth
DOAdate of admission
DOEdyspnea on exertion
DSADigital Subtraction Angiography
DTdelirium tremens
DTPADiethylene-triamine-penta-acetic acid Scan
DVTdeep vein thrombosis
DWdistilled water; dry weight
Dxdiagnosis
DXRTDeep X-Ray Therapy
D&VDiarrhea and vomiting
EBLEstimated blood loss
ECEnteric coated
E coliEscherichia coli
ECFExtended care facility
ECG or EKGElectrocardiogram
ECMOExtracorporeal membrane oxygenation
ECVExtracellular volume
ECWExtracellular water
EDEmergency Department
EDCExpected date of confinement
EMSEmergency Medical Services
EEGElectroencephalogram
EENTEyes, Ears, nose, throat
EEPEnd expiratory pressure
EFEjection fraction
ET or ETTEndotracheal tube
EGAEstimated gestational age
ELISAEnzyme linked immunosorbent assay (immunological testing)
EPAPExpiratory positive airway pressure
EPIEpinephrine
EPOErythropoietin
ETEndotracheal tube
ETDEstimated time of death
°FFahrenheit
FBSFasting blood sugar
FFForce fluids
FeIron
FHRFetal heart rate
FHxFamily history
ft Foot
FTBFull-Thickness Burn
FxFracture
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Daisy Abastar holds a degree in Bachelor of Science in Nursing. Her work experiences include Nursing Local Board Examination Reviewer, Clinical Instructor, NC2 Examination Reviewer and Caregiver Lecturer. Subjects handled: Psychiatric, Obstetric, Pediatric and Fundamentals of Nursing. She also specialized in these areas: ER, Orthopedic Ward and the DR. In addition to passing NLE, she also passed IELTS examination. Her written works are combined learning from theoretical to actual nursing background and ongoing research.