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.
Every facility has its own set of approved abbreviations, symbols, and acronyms. It is important to get to know your facility’s list of abbreviations to avoid confusion in the 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.
Nursing Abbreviations List
| 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 |
