Common Medical Documentation Abbreviations & Symbols

question

Abdomen
answer

Abd
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Acute myocardial infarction
answer

AMI
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Approximate
answer

~ ~
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At
answer

@
question

Arterial blood gas
answer

ABG
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Abdominal aortic aneurysm
answer

AAA
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Adult respiratory distress syndrome
answer

ARDS
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Against medical advice
answer

AMA
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Alert and oriented
answer

A/O
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Anterior
answer

Ant
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As needed
answer

prn
question

Automated external defibrillator
answer

AED
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Advanced life support
answer

ALS
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Blood sugar
answer

BS
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Bilateral
answer

bilat
question

Basic life support
answer

BLS
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Cardiopulmonary resuscitation
answer

CPR
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Chest X-ray
answer

CXR
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Central Nervous System
answer

CNS
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Cerebrospinal fluid
answer

CSF
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Complains/Complaining of
answer

c/o
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Cubic centimeter
answer

cc
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Centimeter
answer

cm
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Chest Pain
answer

CP
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Chronic Obstructive Pulmonary Disease
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COPD
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Carbon Monoxide
answer

Co
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Cardiovascular
answer

CV
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Change
Change
answer

question

Chief Complaint
answer

CC
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Cerebrovascular accident
answer

CVA
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Clear
answer

cl
question

Continuous positive airway pressure
answer

CPAP
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Cerebral Palsy
answer

CP
question

Central venous pressure
answer

CVP
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Cancer
answer

CA
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Congestive Heart Failure
answer

CHF
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Date of birth
answer

DOB
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Dead on arrival
answer

DOA
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Decreased
Decreased
answer

question

Do not resuscitate
answer

DNR
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Diagnosis
answer

Dx
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Diabetes Mellitus
answer

DM
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Ear, Nose, & Throat
answer

ENT
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Electroencephalogram
answer

EEG
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Estimated time of arrival
answer

ETA
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Electrocardiogram
answer

ECG
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Endotracheal tube
answer

ETT
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Extremity
answer

ext
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Fracture
answer

fx
question

Four times per day
answer

qid
question

Gastrointestinal
answer

GI
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Gram
answer

g or gm
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Gunshot wound
answer

GSW
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Gynecological
answer

GYN
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Genitourinary
answer

GU
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Headache
answer

HA or H/A
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Heart rate
answer

HR
question

Heart sounds
answer

HS
question

History & Physical
answer

H&P
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Head, eyes, ears, nose & throat
answer

HEENT
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Hemoglobin
answer

Hgb
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History
answer

Hx
question

Hour
answer

h or hr
question

Immediately
answer

stat
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Increased
Increased
answer

question

Intracardiac
answer

IC
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Intramuscular
answer

IM
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Intraosseous
answer

IO
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Irregular
answer

irreg
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Intensive Care Unit
answer

ICU
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Inferior
answer

Inf
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Intravenous
answer

IV
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Intravenous push
answer

IVP
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Joint
answer

jt
question

Jugular venous distention
answer

JVD
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Kilogram
answer

kg
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Laceration
answer

Lac
question

Left
answer

L
question

Left Lower Quadrant
answer

LLQ
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Liters per minute
answer

LPM or L/min
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Level of consciouness
answer

LOC
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Less than
answer

<
question

Liter
answer

L
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Left Ventricular Hypertrophy
answer

LVH
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Male
Male
answer

question

Medications
answer

Med or Meds
question

Milliequivalent
answer

mEq
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Milliliter
answer

ml
question

Moderate
answer

Mod.
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Milligram
answer

mg
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Millimeter
answer

mm
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Minute
answer

min
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More than
answer

>
question

Nausea & vomiting
answer

N/V
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No known allergies
answer

NKA
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Normal range of motion
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NROM
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Nothing by mouth
answer

NPO
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negative
answer

question

Nasogastric
answer

NG
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No known drug allergies
answer

NKDA
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Not applicable
answer

N/A
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Obstetrical
answer

OB
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Occasional
answer

Occ
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Orally
answer

po
question

Operating room
answer

OR
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Overdose
answer

OD
question

Oxygen
Oxygen
answer

question

Pain
answer

Pn or Px
question

Patient
answer

Pt
question

Palpation
answer

Palp
question

Past medical history
answer

PMH
question

Pelvic Inflammatory Dis.
answer

PID
question

penicillin
answer

PCN
question

Physical Exam
answer

PE
question

Positive
answer

+
question

Posterior
answer

Post.
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Pounds per square inch
answer

psi
question

premature ventricular contracions
answer

PVC
question

Prior to arrival
answer

PTA
question

Privately owned vehicle
answer

POV
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Pulmonary Embolism
answer

PE
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Pupils equal and reactive to light
answer

PEARL
question

Radiates to
Radiates to
answer

question

Range of motion
answer

ROM
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Respiratory or Respirations
answer

Resp
question

Right
answer

R
question

Regarding
answer

re
question

Right upper quadrant
answer

RUQ
question

Right lower quadrant
answer

RLQ
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Rule out
answer

R/O
question

Shortness of breath
answer

SOB
question

Signs and Symptoms
answer

S&S or S/S
question

Sublingual
answer

SL
question

Sudden infant death syndrome
answer

SIDS
question

Superior
answer

Sup.
question

Subcutaneous
answer

SC or SQ
question

Temporomandibular joint
answer

TMJ
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Three times per day
answer

tid
question

Times (multiply)
answer

X
question

Treatment
answer

Tx
question

Two times per day
answer

bid
question

Therapy or Treatment
answer

Rx
question

To keep open
answer

TKO
question

Transport or Transmit
answer

Tx
question

Transient ischemic attack
answer

TIA
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Tuberculosis
answer

TB
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Times
answer

X
question

Unknown
answer

unk
question

Upper respiratory infection
answer

URI
question

Urinary tract infection
answer

UTI
question

Unconscious
answer

Unc
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Vital Signs
answer

VS
question

Weight
answer

Wt
question

Without
answer

w/o
question

Well-developed/well-nourished
answer

WD/WN
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Year-old
answer

y/o
question

Within normal limits
answer

WNL

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