Hello all!
This was a suggestion from a reader to list out some common abbreviations used in medical charting. By no means is it comprehensive, but a good place to start. If you are undergoing scribe training they should have a packet of abbreviations for you to learn; many of which will be similar. If you are in a medical professional school you will also be exposed to these terms. Hope this helps and good luck studying!
Common Charting:
- CC: chief complaint
- C/o: complains of
- DDX: differential diagnosis
- Dx: diagnosis
- D/c: discharge or discontinue
- HPI: history of present illness
- h/o: history of
- H&P: history and physical
- ICU: intensive care unit
- obs: observation unit
- PMHx: past medical history
- PSHx: past surgical history
- All: allergies (not always used)
- FHx: family history
- ROS: review of systems
- PE: physical exam/pulmonary embolism
- MDM: medical decision making
- NPO: nothing by mouth
- PO: by mouth
- PRN: as needed
- qd: each day
- q2h: every 2 hours
- q3h: every 3 hours
- qAM: every morning
- qhs: every bedtime
- qPM: every evening
- BID: twice a day
- TID: three times a day
- QID: four times a day
- qod: every other day
- r/o: rule out
- s/p: status post
- nl: normal
- WNL: within normal limits
- Sx: symptoms
- SubQ or SQ: subcutaneous
- pt: patient
Common Symptoms/Complaints
- F/C: fevers, chills
- HL: hearing loss
- PND: post-nasal drip/paroxysmal nocturnal dyspnea
- CP: chest pain
- SOB: shortness of breath
- O2: oxygen
- abd: abdominal
- N/V: nausea/vomiting
- N/V/D: nausea/vomiting/diarrhea
- MSK: musculoskeletal
- HA: headache
- LOC: loss of consciousness
- BM: bowel movement
- MVA: motor vehicle accident
Physical Exam:
- VSS: vital signs stable
- RR: respiratory rate
- HR: heart rate
- SpO2: pulse ox
- T or Temp: temperature
- BP: back pain or blood pressure
- HEENT: head, eyes, ears, nose, throat
- AT/NC: atraumatic, normocephalic
- PERRL: pupils equal, round, reactive to light
- EOMI: extra-ocular movements intact
- TM: tympanic membrane
- EAC: external auditory canal
- IAC: internal auditory canal
- A&Ox3: alert and oriented x3
- RRR: regular rate and rhythm
- m/r/g: murmurs/rubs/gallops
- tachy: tachycardic
- brady: bradycardic
- AKA: above the knee amputation
- BKA: below the knee amputation
- Ant: anterior
- post: posterior
- bil: bilateral
- LUE: left upper extremity
- RUE: right upper extremity
- BUE: bilateral upper extremities
- LLE: left lower extremity
- RLE: right lower extremity
- BLE: bilateral lower extremities
- RUQ: right upper quadrant
- LUQ: left upper quadrant
- RLQ: right lower quadrant
- LLQ: left lower quadrant
- BPM: beats per minute
- PAC: premature atrial contraction
- PVC: premature ventricle contraction
- CTAB: clear to auscultation bilaterally
- s/nd/nt: soft, non distended, non-tender
- c-spine: cervical spine
- t-spine: thoracic spine
- l-spine: lumbar spine
- Fx: fracture
- FB: foreign body
- FHT: fetal heart tones
- GI: gastrointestinal
- GU: genitourinary
- ICP: intracranial pressure
- IM: intramuscular
- IUD: intrauterine device
- LMP: last menstrual period
- NKA or NKDA: no known allergies or no known drug allergies
Labs and Imaging:
- NSR: normal sinus rhythm
- EKG: electrocardiogram
- CXR: chest xray
- CT: computed tomography
- MRI: magnetic resonance imaging
- Cx: culture
- Bx: biopsy
- FNA: fine needle aspiration
- CBC: complete blood count
- BMP: basic metabolic panel
- CMP: comprehensive metabolic panel
- LFT’s: liver function tests
- ABG: arterial blood gas
- LP: lumbar puncture
- CSF: cerebral spinal fluid
- ESR: erythrocyte sedimentation rate
- EtOH: alcohol
- H&H: hemoglobin and hematocrit
- HCG: human chorionic gonadotropin
- hct: hematocrit
- Hgb or Hb: hemoglobin
- KUB: kidneys, ureter, bladder (this is an X-ray)
- LDH: lactate dehydrogenase
- PT: prothrombin time
- PTT: partial prothromboplastin time
- UA: urinalysis
- US: ultrasound
- BUN: blood urea nitrogen
- GFR: glomerular filtration rate
Common Diagnoses:
- MI: myocardial infarction
- CVA: cerebrovascular accident
- DM: diabetes mellitus
- NIDDM: non-insulin dependent diabetes mellitus
- IDDM: insulin dependent diabetes mellitus
- CAD: coronary artery disease
- ACS: acute coronary syndrome
- PID: pelvic inflammatory disease
- SVT: supraventricular tachycardia
- A fib: atrial fibrillation
- UTI: urinary tract disease
- URI: upper respiratory infection
- SIDS: sudden infant death syndrome
- SBO: small bowel obstruction
- CA: cancer
- ARDS: acute respiratory distress syndrome
- AOM: acute otitis media
- DT’s: delerim tremens
- CHF: congestive heart failure
- PNA: pneumonia
- PTX: pneumothorax
Hope that was helpful!
