Commonly Used Acceptable

Medical and Hospital

Abbreviations

Prepared by:
Jo Maree Pearl Oyco, RN
Mae G. Mallorca, RN,
MAN
Time of Administration

ac ---------- before meals (ante cibum)

q4h ---------- every 4 hours
pc---------- after meals (post cibum)
q6h ---------- every 6 hours
od ---------- daily/once a day (omni die)
qd ---------- everyday (quaque die)
 Bid ---------- two times daily/twice Daily/2x
a day (bis in die)
prn ---------- when necessary (pro renata)
Stat ---------- at once/immediately(statim)
AM ---------- morning (ante meridiem)
PM ---------- afternoon (post meridiem)
Tid ---------- 3x a day
Qid ---------- 4x a day
h(hr)--------- hour (hora)
OM ---------- each morning
qhs --------- at bed time (hora somni)
Alt. ---------- alternate days
Alt her ---------- alternate night
M et N ---------- morning and nig
Alt nect ---------- alternate nights
q ---------- every (quaque)
QOD ---------- alternate day/ every other day
q1h ---------- every hour
q2h ---------- every 2 hours
Dosage and Application

gtt ---------- drops (guttae)

OS ---------- left eye (oculus sinister);

kg ---------- kilogram, a thousand grams

OU ---------- both eyes

L. ---------- a liter,

IM ---------- intramuscular

SC ---------- subcutaneous
IV ---------- intravenous

mL ---------- milliliter, a thousandth liter

NPO (NBM) --- nothing by mouth

KSS------------------ Keep Set Sterile

No. (#) ---------- number

KVO --------------- Keep Vein Open

ID ---------- intradermal
Preparation of Drugs

Amp ------------ampule

Amt ------------amount

Aq/H2O ----------- water

Cap. -----------capsule

Dist. ------------distilled

S. or Sig. ----give the following directions

Rx ----------take
C -----------with

S -----------without

OD -----------right eye (oculus dexter)

OS -----------left eye (oculus sinister); overdose

OU -----------both eyes

IV -----------intravenous
▪
ACCEPTABLE INITIALS AND ABBREVIATIONS

Adm -----------------admission

Abd. -----------------abdomen

ADL -----------------activities of daily living

Ad Lib ---------------as desired (ad libitum)

Amb -----------------ambulatory

approx.-------------approximately
CC ------------------chief complaint

C --------------------Celsius

CBC ----------------complete blood count

Cl -------------------client

c/o -------------------complains of

CNS -----------------central nervous system

CSF ------------------cerebrospinal fluid

CO2 -----------------carbon dioxide

BP -----------------blood pressure

BR -----------------bed rest

BRP ---------------bathroom privileges

BUN ---------------Blood Urea Nitrogen

Cldy ----------------cloudy

DAT ---------------diet as tolerated

D&C -------------dilatation and curettage

DOA --------------dead on arrival

I&O --------------intake and output

Lab ----------------laboratory

LMP --------------last menstrual period

Meds --------------medication

Mod ---------------moderate

Neg----------------negative
COMMONLY USED SYMBOLS

♀---------- female

♂---------- male

> ---------- greater than

< ---------- less than

= ---------- equal

↑ ---------- increased
↓ ---------- decreased

° ---------- degree

@ -------------at

X -------------times

# -------------number, fracture

ō -------------0
Terms Used in Charting
 Concerning Concept to be Suggested Terms to be
Charted Used
Abdomen
1. Black and blue marks 1. Bruised
present 2. Hard, rigid
2. Hard, board-like 3. Tympanites
3. Filled with gas 4. Distended
4. Appearance swollen 5. Rash present (mild,
5. Presence of rash severe)
6. Hurts when touched 6. Sensitive to touch,
tender
 Concerning Concept to be Suggested Terms to be
Charted Used

Admission or 1. Walking 1. Ambulatory

discharge of 2. Carried in (infant) 2. Arm borne
patient 3. On stretcher 3. Per stretcher
4. By Wheelchair 4. Per wheelchair
 Concerning Concept to be
Charted
Amount 1. Large amount
2. Moderate amount
3. Small amount
Suggested Terms to be
Used
1. Profuse, copious,
free, measured amount
2. Moderate, usual,
measured amount
3. Small amount,
scanty, slight, very
little, measured amount
 Concerning Concept to be Suggested Terms to be
Charted Used

Appearance 1. Thin, 1.Emaciated

undernourished
2. Fat, greatly 2.Obese
overweight 3.Acutely ill
3. Seems very sick 4.Not acutely ill
4. Not very sick
 Concerning Concept to be
Charted
Appetite 1. Very fussy about
food, refuse to eat
many food
2. Eats all food served
3. Eats very little
4. Loss of appetite
5. Refuse to eat
Suggested Terms to be
Used
1. Has like and dislike
concerning food
2. Good appetite
3. Poor appetite
4. Anorexic
5. Refused food (state
reason)
 Concerning Concept to be Suggested Terms to be
Charted Used

Arm 1. Shoulder to elbow 1. Upper arm (right or

2. Elbow to wrist left)
3. Appear puffy and 2. Lower arm (right or
swollen left)
4. Artificial arm 3. Edematous
4. Prosthesis (right or
left)
 Concerning Concept to be Suggested Terms to be
Charted Used

Attitude (mental) 1. Not interested in 1. Indifferent

surroundings 2. Apathetic
2. Has “don’t care” 3. Doesn’t believe
attitude anything said to
3. Suspicious, distrustful him/her
4. Quarrelsome, 4. Belligerent,
disagreeable, wants to quarrelsome.
argue Disagreeable
5. Afraid, worried 5. Anxious, fearful
6. Happy, carefree, 6. Cheerful, optimistic
cheerful
 Concerning Concept to be Suggested Terms to be
Charted Used

Back 1. Upper back 1. Interscapular region,

2. Small back shoulder area
3. End of spine 2. Lumbar region
4. Gluteal area 3. Sacral region
5. Hump back 4. Buttocks
6. Sway back 5. Kyphosis
6. Lordosis
 Concerning Concept to be Suggested Terms to be
Charted Used

Baths 1. Given when patient is 1. Admission bath

admitted 2. Complete bath
2. All-inclusive bath 3. Partial bath
3. Including face, arms, 4. Name of bath (e.g.
axilla, genitalia sponge bath)
4. Special baths 5. Tub bath
(treatment0 6. Self-administered,
5. Taken in tub assisted with, bed
6. Taken in bed, by patient bath
 Concerning Concept to be Suggested Terms to be
Charted Used

Bleeding 1. Spurting of blood 1. In spurts

2. Very little 2. Oozing
3. Nose blood 3. Epistaxis
4. Blood in vomitus 4. Hematemesis
5. Blood in urine 5. Hematuria
6. Spitting of blood 6. Hemoptysis
7. The bleeding is stopped 7. Hemorrhage is controlled
8. Bleeding 8. Gross blood/hemorrhage
 Concerning Concept to be Suggested Terms to be
Charted Used

Breath 1. Unpleasant 1. Halitosis

2. Foul 2. Fetid
3. With sweet fruit 3. Fruity, sweet
like odor 4. Alcoholic
4. Smells like alcohol
 Concerning Concept to be Suggested Terms to be
Charted Used

Blood 1. High blood 1. Hypertensive

pressure pressure 2. Hypotensive
2. Low blood
pressure
 Concerning Concept to be Suggested Terms to be
Charted Used
Breathing 1. Act of breathing 1. Respiration
2. Act of inhaling 2. Inspiration
3. Act of exhaling 3. Expiration
4. Difficulty in breathing 4. Dyspnea
5. Short period of breathing cessation5. Apnea
6. Inability to breathe in supine 6. Orthopnea
position 7. Eupnea
7. Normal breathing 8. Hyperpnea
8. Rapid breathing 9. Cheyne-stokes
9. Increasing dyspnea with period of respiration
apnea 10. Deep breathing
10. Large volume of air inhaled 11. Shallow breathing
11. Small volume of air inhaled 12. Asphyxia
12. Suffocation
 Concerning Concept to be Suggested Terms to be
Charted Used
Care 1. Wash face and hands, 1. Early A.M. care
oral hygiene 2. Routine A.M. care
2. Bath, alcohol backrub, 3. P.M. care
bedpan, oral hygiene 4. Special care to mouth
3. Wash hands, face and and back
back
4. Special attention or
treatment of mouth or
back as ordered by the
doctor
 Concerning Concept to be Suggested Terms to be
Charted Used

Consciousness 1. Fully conscious, aware of 1. Alert, fully

surroundings conscious
2. Only partly conscious 2. Time conscious
3. Unconscious, but can be aroused 3. Stuporous
4. Unconscious, cannot be aroused 4. Comatose
5. Unawareness of time and place 5. Disoriented
 Concerning Concept to be Suggested Terms to be
Charted Used

Cough 1. Coughs all the time 1. Continuous cough

2. Coughing over long periods of time 2. Persistent cough
3. Cough out materials 3. Productive cough
4. Occurring in spasms to describe a 4. Spasmic
cough from the lungs 5. Non-productive cough
5. Cough does not produce materials 6. Frequent cough
6. Cough quite often 7. Tight, loose, deep, dry, hacking, painful,
7. Other self-explanatory terms used rasping, exhaustive, rash
 Concerning Concept to be Suggested Terms to be
Charted Used

Gait 1. Dragging loosely 1. Paralytic

2. Duck-like walk 2. Waddling
3. Unsteady, shaky 3. Tottering
4. Walk dizzily, as in 4. Staggering, reeling
alcoholic 5. Stamping
5. Strike foot forcibly
downward
 Concerning Concept to be Suggested Terms to be
Charted Used
Pain Great pain Severe
Little pain Slight
Comes in seizures Paroxysmal, spasmodic
Spread in distant areas Radiating
Started all at once Sudden onset
Hurt worst when moving Increased by moving
Other descriptive terms Sharp, sudden, darting, gnawing,
burning, stabbing, cramping, localized,
superficial, agonizing, transient,
constant, shifting, sheathing, colicky,
persistent, deep
Wounds 1. Deep 1. Deep
2. Slight, surface only 2. Superficial
3. Not infected 3. Clean
4. Discharging pus 4. Suppurating
5. Infected 5. Infected
6. Torn 6. Lacerated