Wondering why you can’t read what the doctor wrote on your prescription? Ever see the doctor’s notes in your medical record and found peculiar abbreviations and jargon? Doctors commonly use a variety of abbreviations in order to rapidly and succinctly record information about, and give instructions to, their patients. Below is a listing of many common terms and abbreviations defined so that you can decipher those charts
a.c.: Before meals. As in taking a medicine before meals.
a/g ratio: Albumin to globulin ratio.
ACL: Anterior cruciate ligament. ACL injuries are one of the most commonligament injuries to the knee. The ACL can be sprained or completely torn from trauma and/or degeneration.
Ad lib: At liberty. For example, a patient may be permitted to move out of bed freely and orders would, therefore, be for activities to be ad lib.
AKA: Above the knee amputation.
Anuric: Not producing urine. A person who is anuric is often critical and may require dialysis.
b.i.d.: Twice daily. As in taking a medicine twice daily.
Bandemia: Slang for elevated level of band forms of white blood cells.
Bibasilar: At the bases of both lungs. For example, someone with apneumonia in both lungs might have abnormal bibasilar breath sounds.
BKA: Below the knee amputation.
BMP: Basic metabolic panel. Electrolytes (potassium, sodium, carbon dioxide, and chloride) and creatinine and glucose.
BP: Blood pressure. Blood pressure is recorded as part of the physical examination. It is one of the “vital signs.”
BSO: Bilateral salpingo-oophorectomy. A BSO is the removal of both of the ovaries and adjacent Fallopian tubes and often is performed as part of a total abdominal hysterectomy.
C&S: Culture and sensitivity, performed to detect infection.
C/O: Complaint of. The patient’s expressed concern.
CBC: Complete blood count.
CC: Chief complaint. The patient’s main concern.
cc: Cubic centimeters. For example, the amount of fluid removed from the body is recorded in ccs.
Chem panel: Chemistry panel. A comprehensive screening blood test that indicates the status of the liver, kidneys, and electrolytes.
COPD: Chronic obstructive pulmonary disease.
CVA: Cerebrovascular accident (Stroke).
D/C or DC: Discontinue or discharge. For example, a doctor will D/C a drug. Alternatively, the doctor might DC a patient from the hospital.
DDX: Differential diagnosis The variety diagnostic possibilities being considered.
DM: Diabetes mellitus.
DNC, D&C, or D and C: Dilation and curettage. Widening the cervix and scrapping with a curette for the purpose of removing tissue lining the inner surface of the womb (uterus).
DNR: Do not resuscitate. This is a specific order not to revive a patient artificially if they succumb to illness. If a patient is given a DNR order, they are not resuscitated if they are near death and no code blue is called.
DOE: Dyspnea on exertion. Shortness of breath with activity.
DTR: Deep tendon reflexes. These are reflexes that the doctor tests by banging on the tendons with a rubber hammer.
DVT: Deep venous thrombosis (Blood clot in large vein).
ETOH: Alcohol. ETOH intake history is often recorded as part of a patient history.
GOMER: Slang for “get out of my emergency room.”
H&H: Hemoglobin and hematocrit. When the H & H is low, anemia is present. The H&H can be elevated in persons who have lung disease from long term smoking or from disease, such as polycythemia rubra vera.
H&P: History and physical examination.
h.s.: At bedtime. As in taking a medicine at bedtime.
H/O or h/o: History of. A past event that occurred.
I&D: Incision and drainage.
IM: Intramuscular. This is a typical notation when noting or ordering an injection (shot) given into muscle, such as with B12 for pernicious anemia.
IMP: Impression. This is the summary conclusion of the patient’s condition by the healthcare practitioner at that particular date and time.
in vitro: In the laboratory.
in vivo: In the body.
IU: International units.
K: Potassium. An essential electrolyte frequently monitored regularly in intensive care.
KCL: Potassium chloride.
LBP: Low back pain. LBP is one of most common medical complaints.
LLQ: Left lower quadrant. Diverticulitis pain is often in the LLQ of theabdomen.
LUQ: Left upper quadrant. The spleen is located in the LUQ of the abdomen.
Lytes: Electrolytes (potassium, sodium, carbon dioxide, and chloride).
MCL: Medial collateral ligament.
MVP: Mitral valve prolapse.
N/V: Nausea or vomiting.
Na: Sodium. An essential electrolyte frequently monitored regularly in intensive care.
npo: Nothing by mouth. For example, if a patient was about to undergo a surgical operation requiring general anesthesia, they may be required to avoid food or beverage prior to the procedure.
O&P: Ova and parasites. Stool O & P is tested in the laboratory to detectparasitic infection in persons with chronic diarrhea.
O.D.: Right eye.
O.S.: Left eye.
O.U.: Both eyes.
ORIF: Open reduction and internal fixation, such as with the orthopedic repair of a hip fracture.
P: Pulse. Pulse is recorded as part of the physical examination. It is one of the “vital signs.”
p.o.: By mouth. From the Latin terminology per os.
p.r.n.: As needed. So that it is not always done, but done only when the situation calls for it (or example, taking a pain medication only when having pain and not without pain).
PCL: Posterior cruciate ligament.
PERRLA: Pupils equal, round, and reactive to light and accommodation.
Plt: Platelets, one of the blood forming elements along with the white and red blood cells.
PMI: Point of maximum impulse of the heart when felt during examination, as in beats against the chest.
q.d.: Each day. As in taking a medicine daily.
q.i.d.: Four times daily. As in taking a medicine four times daily.
q2h: Every 2 hours. As in taking a medicine every 2 hours.
q3h: Every 3 hours. As in taking a medicine every 3 hours.
qAM: Each morning. As in taking a medicine each morning.
qhs: At each bedtime. As in taking a medicine each bedtime.
qod: Every other day. As in taking a medicine every other day.
qPM: Each evening. As in taking a medicine each evening.
R/O: Rule out. Doctors frequently will rule out various possible diagnoses when figuring out the correct diagnosis.
REB: Rebound, as in rebound tenderness of the abdomen when pushed in and then released.
RLQ: Right lower quadrant. The appendix is located in the RLQ of the abdomen.
ROS: Review of systems. An overall review concerns relating to the organsystems, such as the respiratory, cardiovascular, and neurologic systems.
RUQ: Right upper quadrant. The liver is located in the RUQ of the abdomen.
s/p: Status post. For example, a person who had a knee operation would be s/p a knee operation.
SOB: Shortness of breath.
SQ: Subcutaneous. This is a typical notation when noting or ordering an injection (shot) given into the fatty tissue under the skin, such as with insulinfor diabetes mellitus.
T: Temperature. Temperature is recorded as part of the physical examination. It is one of the “vital signs.”
T&A: Tonsillectomy and adenoidectomy.
t.i.d.: Three times daily. As in taking a medicine three times daily.
TAH: Total abdominal hysterectomy.
THR: Total hip replacement.
TKR: Total knee replacement.
UA or u/a: Urinalysis. A UA is a typical part of a comprehensive physical examination.
URI: Upper respiratory infection, such as sinusitis or the common cold.
ut dict: As directed. As in taking a medicine according to the instructions that the healthcare practitioner gave in the office or in the past.
UTI: Urinary tract infection.
VSS: Vital signs are stable. This notation means that from the standpoint of the temperature, blood pressure, and pulse, the patient is doing well.