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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

Assessment Data


Assessment data

ax

axillary


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B/P

Blood pressure


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BM

Bowel movement


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BSA

Body surface area


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bx

biopsy


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C

Celsius (temp scale)


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c/o

Complaints of


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cc

Chief complaint


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DOA

Dead on arrival


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dx

Diagnosis


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F

Fahrenheit (temp scale)


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h/o

History of


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H&P

History and physical


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HR

Heart rate


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LMP

Last menstrual period


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LOC

Level of consciousness


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NG

nasogastric


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OTC

Over the counter

(medicine without a prescription)


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P

pulse


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PE

Physical exam


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PMH

Past medical history


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R

respiration


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R/O

Rule out


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ROM

Range of motion


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ROS

Review of systems


Rx rx

RX (Rx)

Prescription/treatment


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SOA

Short of air


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sx

Signs/symptoms


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T

temperature


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TCDB

Turn, cough, deep, breathe


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TPR

Temperature, Pulse, Respiration


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VS

Vital signs


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WNL

Within normal limits


Disease related terms

Disease Related Terms


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AIDS

Acquired immune deficiency syndrome


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ASHD

Arteriosclerotic heart disease


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BPH

Benign prostatic hyperplasia


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CA

cancer


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CHF

Congestive heart failure


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CAD

Coronary artery disease


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COPD

Chronic obstructive pulmonary disease


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CVA

Cerebrovascular accident


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DM

Diabetes mellitus


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FUO

Fever of unknown origin


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fx

fracture


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GI

gastrointestinal


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GU

genitourinary


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HTN

hypertension


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MI

Myocardial infarction


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PVC

Premature ventricular contraction


Std sti

STD (STI)

Sexually transmitted disease (sexually transmitted infection)


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URI

Upper respiratory infection


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UTI

Urinary tract infection


Orders

ORDERS


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a

before


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ac

Before meals


Ad lib

ad lib

At will; as desired


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AMA

Against medical advice


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bid

Two times a day (bi-daily)


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c

with


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CPR

Cardiopulmonary resuscitation


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D/W

Dextrose in water


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DNR

Do not resuscitate


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DSD

Dry sterile dressing


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g, Gm

gram


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gr

grain


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gtt

drop


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h

hour


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hs

Hour of sleep; bedtime


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I&O

Intake and output


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IM

intramuscular


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IV

intravenous


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mL

milliliter


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NPO

Nothing by mouth

(nothing put orally)


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NS

Normal saline


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OT

Occupational therapy


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P

After

(post)


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PO

Per mouth

(Put orally)


Post op

Post op

Post operative

(post operation)


Preop

preop

Preoperative

(before operation)


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prn

As needed; whenever necessary (per required need)


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pt

patient


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P.T.

Physical therapy


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q

every


Q4h q6h q8h

q4h; q6h; q8h

Every 4,6,8 hours


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qid

Four times a day

(quad)


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s

Without

**sin**


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STAT

At once; immediately


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T&C

Type and crossmatch


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tx

treatment


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tid

Three times a day


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x

times


Client activity

Client Activity


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ADL

Activities of daily living


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AMB

ambulatory


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BRP

Bathroom privileges


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CBR

Complete bed rest


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OOB

Out of bed


Up ad lib

up ad lib

Up as desired


Wc or w c

wc or w/c

Wheel chair


Studies elements and measures

Studies, elements and measures


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ABGs

Arterial blood gasses


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BE

Barium enema


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C&S

Culture and sensitivity


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CBC

Complete blood count


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Cl

chloride


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cm

centimeter


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CO

Carbon monoxide


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CO2

Carbon dioxide


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CSF

Cerebral spinal fluid


Ecg ekg

ECG/EKG

electrocardiogram


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EEG

electroencephalogram


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Hgb

hemoglobin


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Hct

hematocrit


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ICP

Intracranial pressure


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K

potassium


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Kcal

Kilocalories (food calorie)


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Kg

kilogram


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L

liter


Lytes

lytes

electrolytes


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m

meter


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mEg

milliequivalent


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Mg

magnesium


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mg

milligram


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mm

millimeter


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MRI

Magnetic resonance imaging


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N

nitrogen


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Na

sodium


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NaCl

Sodium chloride; salt


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O2

oxygen


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oz

ounce


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RBC

Red blood cells


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tbsp

tablespoon


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tsp

teaspoon


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UA

urinalysis


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WBC

White blood cells


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wt

weight


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