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Assessment Data. ax. axillary. B/P. Blood pressure. BM. Bowel movement. BSA. Body surface area. bx. biopsy. C. Celsius (temp scale). c/o. Complaints of. cc. Chief complaint. DOA. Dead on arrival. dx. Diagnosis. F. Fahrenheit (temp scale). h/o. History of. H&P.

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Assessment Data

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Assessment Data


ax

axillary


B/P

Blood pressure


BM

Bowel movement


BSA

Body surface area


bx

biopsy


C

Celsius (temp scale)


c/o

Complaints of


cc

Chief complaint


DOA

Dead on arrival


dx

Diagnosis


F

Fahrenheit (temp scale)


h/o

History of


H&P

History and physical


HR

Heart rate


LMP

Last menstrual period


LOC

Level of consciousness


NG

nasogastric


OTC

Over the counter

(medicine without a prescription)


P

pulse


PE

Physical exam


PMH

Past medical history


R

respiration


R/O

Rule out


ROM

Range of motion


ROS

Review of systems


RX (Rx)

Prescription/treatment


SOA

Short of air


sx

Signs/symptoms


T

temperature


TCDB

Turn, cough, deep, breathe


TPR

Temperature, Pulse, Respiration


VS

Vital signs


WNL

Within normal limits


Disease Related Terms


AIDS

Acquired immune deficiency syndrome


ASHD

Arteriosclerotic heart disease


BPH

Benign prostatic hyperplasia


CA

cancer


CHF

Congestive heart failure


CAD

Coronary artery disease


COPD

Chronic obstructive pulmonary disease


CVA

Cerebrovascular accident


DM

Diabetes mellitus


FUO

Fever of unknown origin


fx

fracture


GI

gastrointestinal


GU

genitourinary


HTN

hypertension


MI

Myocardial infarction


PVC

Premature ventricular contraction


STD (STI)

Sexually transmitted disease (sexually transmitted infection)


URI

Upper respiratory infection


UTI

Urinary tract infection


ORDERS


a

before


ac

Before meals


ad lib

At will; as desired


AMA

Against medical advice


bid

Two times a day (bi-daily)


c

with


CPR

Cardiopulmonary resuscitation


D/W

Dextrose in water


DNR

Do not resuscitate


DSD

Dry sterile dressing


g, Gm

gram


gr

grain


gtt

drop


h

hour


hs

Hour of sleep; bedtime


I&O

Intake and output


IM

intramuscular


IV

intravenous


mL

milliliter


NPO

Nothing by mouth

(nothing put orally)


NS

Normal saline


OT

Occupational therapy


P

After

(post)


PO

Per mouth

(Put orally)


Post op

Post operative

(post operation)


preop

Preoperative

(before operation)


prn

As needed; whenever necessary (per required need)


pt

patient


P.T.

Physical therapy


q

every


q4h; q6h; q8h

Every 4,6,8 hours


qid

Four times a day

(quad)


s

Without

**sin**


STAT

At once; immediately


T&C

Type and crossmatch


tx

treatment


tid

Three times a day


x

times


Client Activity


ADL

Activities of daily living


AMB

ambulatory


BRP

Bathroom privileges


CBR

Complete bed rest


OOB

Out of bed


up ad lib

Up as desired


wc or w/c

Wheel chair


Studies, elements and measures


ABGs

Arterial blood gasses


BE

Barium enema


C&S

Culture and sensitivity


CBC

Complete blood count


Cl

chloride


cm

centimeter


CO

Carbon monoxide


CO2

Carbon dioxide


CSF

Cerebral spinal fluid


ECG/EKG

electrocardiogram


EEG

electroencephalogram


Hgb

hemoglobin


Hct

hematocrit


ICP

Intracranial pressure


K

potassium


Kcal

Kilocalories (food calorie)


Kg

kilogram


L

liter


lytes

electrolytes


m

meter


mEg

milliequivalent


Mg

magnesium


mg

milligram


mm

millimeter


MRI

Magnetic resonance imaging


N

nitrogen


Na

sodium


NaCl

Sodium chloride; salt


O2

oxygen


oz

ounce


RBC

Red blood cells


tbsp

tablespoon


tsp

teaspoon


UA

urinalysis


WBC

White blood cells


wt

weight


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