(A) @ aa AA AAL Ab AB abd ABL AC acid phos ACM ACTH A&D ADD ADHD ADL ad lib adm admin

AEB AED AF A-Fib AFB A&P APC appt Apr ARDS ARF AROM ASAP AMAP ASA ASD at affected area Alcoholics Anonymous anterior axillary line antibiotic armband abdomen anticonvulsive blood level before meals acid phosphatase anticonvulsant medications adrenocorticotrophic hormone alcohol and drug attention deficit disorder attention deficit hyperactivity disorder activities of daily living at pleasure, at discretion, freely as desired admission administration as evidenced by automated external defibrillator African-American atrial fibrillation acid fast bacilli auscultation and percussion atrial premature complexes appointment April adult respiratory distress syndrome acute renal failure active range of motion as soon as possible as much as possible aspirin atrial septal defect amal A/G AIDS AIMS AJ AKA alb alg alk phos ALL ALS ALT AMA AMH1 AMH2 AM A.M. amb AML amt ANC A&O AODM A-P A-P & Lat ASHD ASCVD Asst AST A/T Au AU Aug A/V A-V AWOL amalgam albumin globulin ratio acquired immune deficiency syndrome Abnormal Involuntary Movement Scale ankle jerk also known as albumin alginate alkaline phosphatase acute lymphocytic leukemia amyotrophic lateral sclerosis aspartate aminotransferase against medical advice Adult Mental Health 1 Adult Mental Health 2 before noon ambulatory acute myelogenous leukemia amount absolute neutrophil count alert and oriented adult onset diabetes mellitus anterioposterior anterioposterior and lateral arteriosclerotic heart disease arteriosclerotic cardiovascular disease assistant alanine aminotransferase activity therapy gold each ear August auditory / visual atrioventricular absent without leave

(B) B Bact BAL baso BE BEAP Beh Sp Beh Tech B/F BHIS BHL BID bld bl cult BS BTL BTU BUN (C) C C1, C2, etc. Ca CA CABG CAD CAL Calc cap cath CBC CBP CBZ cc CC CCT CDT centigrade cervical vertebrae calcium carcinoma, cancer coronary artery bypass graft coronary artery disease calorie calculus capsule catheter complete blood count Comprehensive Behavior Plan carbamazepine (Tegretol) cubic centimeter chief complaint chronic catatonic type (schizophrenia) chronic disorganized type (schizophrenia) CF CHD CHF CHI CHO Cl CL CLD cldy cm CM CMHC CN CNA CNS C/O col ct cystic fibrosis congenital heart disease congestive heart failure closed head injury carbohydrate chloride clinic complete lower denture cloudy centimeter continuous murmur Community Mental Health Center cranial nerve Certified Nursing Assistant central nervous system complaint of colony count buccal bacterium blood alcohol level basophil barium enema brainstem evoked auditory potential Behavior Specialist Behavior Technician black female Behavioral Health Information System Behavioral Health Link twice a day blood blood culture bowel sounds bilateral tubal ligation British Thermal Units blood urea nitrogen BLT B/M BM BM/E BMR b/o BOP BP BPH BPRS BRBPR br sounds BR BRP BW BWX BZD borderline tracing black male bowel movement bowel movement with enema basal metabolic rate because of blood, ova, parasites blood pressure benign prostate hypertrophy Brief Psychiatric Rating Scale bright red blood per rectum breath sounds bathroom bathroom privileges birth weight bite wing radiograph, bite wing x-ray benzodiazepine

CO2 comp cont COPD CP&PD CPT CPR Cr CR CRF Cr Cl CRT CRU (D) D DBW Derm DD DDS Dec Den DFCS DI diff DIP Disp D/O DOA

carbon dioxide complete continue chronic obstructive pulmonary disease chest percussion and postural drainage chronic paranoid type (schizophrenia) cardiopulmonary resuscitation creatinine conditional release chronic renal failure creatinine clearance chronic residual type (schizophrenia) Consumer Resource Unit

C&S CSH C-Section CSF CT CWR CUD CULD CUT CVA CXR CZP

culture and sensitivity Central State Hospital cesarean cerebrospinal fluid computerized axial tomography cottage weight reduction complete upper denture complete upper and lower dentures chronic undifferentiated type cerebral vascular accident chest x-ray clonazepam (Klonopin)

day desirable body weight dermatology developmental disabilities Doctor of Dental Surgery December dental Department Services diabetes insipidus differential distal interphalangeal (joint) dispense (usually medication) disorder dead on arrival of Family and Children

D&C D/C DOB DON DPT DSM-IV D/T DTR DTs DVT DWR Dx

dilation and curettage discontinue date of birth Director of Nursing Diphtheria pertussis Diagnostic and Statistical Manual Fourth Edition diphtheria/tetanus toxoid deep tendon reflexes delirium tremens deep vein thrombosis desirable weight range diagnosis and tetanus toxoids with

(E) EAC ECHO ECT ECRH EDC EEG EENT eg EKG Elix EMG Endo EMT ENT (F) F FB FBS&2hPP FBR FBS Feb FH fl tr fluoro FM FMX female foreign body fasting blood sugar and 2-hour post prandial full body restraint fasting blood sugar February family history fluoride treatment fluoroscopy full mouth full mouth x-ray FOI FPD Fri FS FSH FSIQ FROM FST F/U FUO Fx flight of ideas fixed partial denture (dental bridge) Friday fever scan (forehead thermometer) follicle stimulating hormone Full Scale Intelligence Quotient full range of motion Forensic Technician follow up fever of undetermined origin fracture external auditory canal ultrasound cardiogram electroconvulsive therapy East Central Regional Hospital estimated date of confinement electroencephalogram eyes, ears, nose, and throat for example electrocardiogram elixir electromyogram endodontics Emergency Medical Technician ears, nose, and throat EOE EOM EOMI eos epi EPS ER ESRD ESR esp EST et ETOH ext extraoral exam extraocular movement (or muscle) EOM intact eosinophil epinephrine extrapyramidal symptoms emergency room end-stage renal disease erythrocyte sedimentation rate especially exercise stress test and alcohol extraction

(G) GA GAD G6PD GB GBMI GBP GC GE GED GERD GFR GF GGT general anesthesia generalized anxiety disorder glucose-6 phosphate dehydrogenase gallbladder guilty but mentally ill gabapentin (Neurontin) gonorrhea, gonococcus, gonococcal gastroesophageal general education development test gastroesophageal reflux disease glomerular filtration rate grandfather gamma glutamyl transpeptidase GSW GSSH GTube GTC gtt GTT GU Gyn GI gm GM gm% gastrointestinal gram grandmother grams per hundred milliliters of serum or blood as specified gunshot wound Gracewood State School and Hospital gastrointestinal tube generalized tonic-clonic (seizures) drop glucose tolerance test genitourinary gynecology

(H) H H/A HBcAb HBsAb HBsAg HBP HC Hct HCP HCTZ HEENT Hgb HHC HI histo HIV HJR hour headache type B hepatitis core antibody type B hepatitis surface antibody type B hepatitis surface antigen high blood pressure hydrocortisone hematocrit Health Care Plan hydrochlorothiazide head, eyes, ears, nose, and throat hemoglobin home health care homicidal ideation histoplasmosis human immunodeficiency virus hepatojugular reflux HPI HRT HS HST HSV ht HTN Hx hyg H2O H202 h/o HO HOB Hosp H&P hpf history of hold order head of bed hospital history and physical high powered field (used only in

describing urine sediments) history of present illness hormone replacement therapy at bedtime Health Service Technician herpes simplex virus height hypertension history hygiene water hydrogen peroxide

(I) I I&D I&O IBW ICCE ICF/MR ICS I131 ID IDT ie Imp INH In Pt IOE incisal incision and drainage intake and output ideal body weight intracapsular cataract extraction Intermediate Care Facility/Mental intercostal space radioactive iodine intradermal interdisciplinary team that is impression isoniazid in patient intraoral exam IOP IQ IRM IM ISP IST ITP IUD IUP IV IVDA IVF IVC IVP IWR intraocular pressure intelligence quotient (Caulk's) intermediate restorative material intramuscular individual service plan incompetent to stand trial idiopathic thrombocytopenia purpura intrauterine device intrauterine pregnancy intravenous IV drug abuse intravenous fluids inferior vena cava intravenous pyelogram ideal weight rang

(J) Jan J&J JMS JMS PN JODM July June (L) L l L1, L2 L/A LA lab lac LAC LAD left (side) liter 1st lumbar vertebra, etc. living area long acting laboratory laceration living area clinic left axis deviation LAE LAH Lat lax lb LBBB LBP LCM left atrial enlargement left atrial hypertrophy lateral laxative pound left bundle branch block lower back pain left costal margin January Johnson Shampoo) Junior Medical Student Junior Medical Student progress note juvenile onset diabetes mellitus July June and Johnson (i.e., Baby (K) k kg KJ KUB KVO potassium kilogram knee jerk kidney, ureter, bladder keep vein open

LDH L-DOPA LE LE prep LFT lg LiCo3 lido Liq LJX LLE LLL LLQ LLSB LM LMD LMG LMP (M) m m Mar mand MGF MGM MH MHC MI MIC Misc ml mm mM MMG MMR MMSE mn mo

lactate dehydrogenase levadopamine lower extremity lupus erythematosus cell preparation liver function tests large lithium carbonate lidocaine liquid lateral jaw x-ray left lower extremity left lower lobe - lung left lower quadrant - abdomen left lower sternal border land mark local medical doctor lamotrigine (Lamictal) last menstrual period

LN LOA LOC LOS LP LPN LPC LR L-S LSB LUE LUL LUQ LV LVE LVH LVT lymphs

lymph node looseness of association loss of consciousness line of sight lumbar puncture Licensed Practical Nurse Licensed Professional Counselor light reflex lumbosacral left sternal border left upper extremity left upper lobe - lung left upper quadrant - abdomen left ventricle left ventricle enlargement left ventricle hypertrophy levetiracetam (Keppra) lymphocytes

male murmur (cardiac) March mandibular max maximum maternal grandfather maternal grandmother mental health mental health center myocardial infarction minimum inhibitory concentrations miscellaneous milliliter or milliliters millimeter millimole mammogram measles/mumps/rubella Mini-Mental Status Exam midnight month

m/o mos MOD MOM Mon MP MR MRE MRI MRSA MSE MSL MTP joint MTP MVA MVP MX

month old months Medical Officer of the Day milk of magnesia Monday mouth prop mental retardation most recent episode Magnetic Resonance Imaging methicillin resistant staph aureus mental status exam midsternal line metatarsophalangeal joint minor treatment protocol motor vehicle accident mitral valve prolapse maxillary

(N) NAD N/A NA Na neg NeuroSurg Neuro NG NGRI NH nl NKA NKDA noc (O) O , O2 O2 cap O2Sat OB obl obs OCD OCBZ Oct OCV ODD OD OE occlusal (surface of tooth) none oxygen oxygen capacity oxygen saturation obstetrics oblique observation obsessive compulsive disorder oxycarbazepine (Trileptal) October off campus oppositional defiant disorder right eye otitis externa OH OHD OM OOB Op Out Pt OPC OPV OR OTR Ortho OS OU OTC O/T oz oral hygiene organic heart disease otitis media out of bed operation outpatient outpatient clinic oral polio vaccine operating room Occupational Therapist, Registered orthopedic left eye both eyes over the counter occupational therapy ounce no acute distress not applicable Nurse Administrator sodium negative neurosurgery neurology nasogastric not guilty by reason of insanity nursing home normal no known allergies no known drug allergies night N/V N/V/D nausea and vomiting nausea, vomiting and diarrhea NOS N20/02 Nov NPN NPO NS NSAID NSDO NSR NSVD not otherwise specified nitrous oxide and oxygen November nonprotein nitrogen nothing by mouth normal saline nonsteroidal anti-inflammatory drug neurosurgery danger orders normal sinus rhythm normal spontaneous vaginal delivery

(P) p P P2 PA P-A PA-C PAL PANSS PAP PAT path PAX PB PBI PC PCN PCH PCV PDA PDL PE PEG PEJ per perio PERL PERRLA PFE PFM PGF PGM pH PH PHR phos PI PID after pulse pulmonic second sound Physicians Assistant posteroanterior Physicians Assistant - Certified posterior axillary line Positive and Negative Syndrome Scale papanicolaou's smear paroxysmal atrial tachycardia pathology periapical x-ray phenobarbital protein bound iodine after meals, post prandial penicillin personal care home packed cell volume patient ductus arteriostosis periodontal ligament physical examination percutaneous gastrostomy percutaneous jejunostony through or by periodontal pupils equal and reactive to light pupils equal, round, reactive to light and accommodation Patient & Family Education porcelain fused to metal (crown) paternal grandfather paternal grandmother hydrogen ion concentration past history periodic health review phosphorus pulmonary insufficiency pelvic inflammatory disease PVC PVD post Post-op PPD PR PPVT-R pre-op prep PRN Prog PROM Prophy psych PSA PT P/T pt PTA PTE PTN PTSD PTT PUD PIP PJC PKU pl ct PM PMH PMI PMS PND PO polys proximal interphalangeal (joint) porcelain jacket crown phenylketonuria platelet count afternoon past medical history plea of mental incompetence premenstrual syndrome paroxysmal nocturnal dyspnea by mouth polymorphonuclear leucocytes (neutrophils) after postoperative purified protein derivative per rectum Peabody Picture Vocabulary Test-Revised pre-operative prepare for, preparation for as necessary, as needed prognosis passive range of motion dental prophylaxis psychiatric prostate specific antigen prothrombin time physical therapy patient prior to admission pretrial evaluation phenytoin (Dilantin) posttraumatic stress disorder partial thromboplastin time peptic ulcer disease obstruction premature ventricular contractions peripheral vascular disease

PUD w/GOO peptic ulcer disease with gastric outlet

(Q) Q QAM Q(x)H QH QHS QID QMRP QPM QSHIFT (R) R RA RAD RAE RAH RAN RBBB RBC RBI RCM RCSD RCT RDH re readm rehab resp retic(s) RF RV RVE right rheumatoid arthritis right axis deviation right atrial enlargement right atrial hypertrophy resident admission note right bundle branch block red blood cell rubber base impression right costal margin Richmond County Sheriffs Department root canal therapy Registered Dental Hygienist regarding readmission rehabilitation respiration reticulocyte(s) rheumatoid factor right ventricle right ventricular enlargement Rh RHD RLE RLL RLQ RML RN R/O ROM ROS RPD RPR RR RRR R/T RTC RUE RUL RUQ RVH Rx rhesus blood factor rheumatic heart disease right lower extremity right lower lobe right lower quadrant right middle lobe lung Registered Nurse rule out range of movement review of systems removable partial denture rapid plasma reagent respiratory rate regular rate and rhythm related to return to clinic right upper extremity right upper lobe - lung right upper quadrant right ventricular hypertrophy prescription, treatment every; each every morning every (x) hours every hour every night at bedtime four times per day Qualified Mental Retardation Professional every afternoon every shift

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(S) S S1 & S2 S3 & S4 Sz D/O Sat SBE SC Anemia SC Trait SE sed segs SEM Sept SGOT SGPT SH SHAPA SI SIADH SIB sib(s) sig: SI joint SI/HI sl SLE SLH SLR sm sign first and second heart sounds heart sounds (physiological) seizure disorder Saturday subacute bacterial endocarditis sickle cell anemia sickle cell trait side effects sedation segmented neutrophils systolic ejection murmur September serum glutamic oxaloacetic transaminase serum glutamic pyruvic transaminase social history Social History and Psychosocial Assessment suicidal ideation inappropriate hormone self-injurious behavior sibling(s) directions for use, label sacroiliac joint suicidal/homicidal ideation slight; slightly systemic lupus erythematous supportive living home straight leg raise small secretion of antidiuretic S-M SMS SNF SOAP SOB SOC soln SOM SP S/P SPF sp gr SQ SS SSC SSD ss enema SSI Staph STAT STD Strep subg Sun Supp Surg susp SVT S/Sx Sx Sz SZAF sensorimotor senior medical student Skilled Nursing Facility Subjective, Objective, Assessment, Plan shortness of breath social solution serous otitis media suicide precaution(s) status-post sun protection factor specific gravity subcutaneous Social Security stainless steel crown Social Security Disability soapsuds enema supplemental security income staphylococcus immediately; at once sexually transmitted disease streptococcus subgingival Sunday suppository surgery; surgical suspension supra-ventricular tachycardia signs/symptoms symptoms seizure schizoaffective

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(T) T T1, T2, etc. T/A T&A TAC TAT tab or tabs TAH temperature 1st thoracic vertebra, etc. tooth ache tonsillectomy and adenoidectomy triamcinolone cream Thematic Apperception Test tablet (tablets) total abdominal hysterectomy salpingo oophorectomy TB Tbsp Td TD temp Temp Flg TFT TGB Thurs TIA (U) UA UBR UDS UE UGI urinalysis upper body restraints urine drug screen upper extremity upper gastrointestinal bowel follow through UH UHBH UHER UP URI US USP UTI UV University Hospital University Hospital Behavioral Health University Hospital Emergency Room ureteropelvic upper respiratory infection ultra-sound United States Pharmacopoeia urinary tract infection ultraviolet tuberculosis tablespoon tetanus/diptheria toxoid tardive dyskinesia temporary temporary filling thyroid function test tiagabine (Gabatril) Thursday transient ischemic attack TID T-L TL TLC TM TMJ TOF Toxo trach Trich TPM TPR tsp TT Tues TURP TV TVH tx tx plan three times daily thoracolumbar temporary leave tender loving care tympanic membrane temporomandibular joint tetralogy of fallot toxoplasmosis tracheostomy trichomonas topiramate (Topamax) temperature, pulse, respiration teaspoon tetanus toxoid Tuesday transurethral resection of prostate trial visit total vaginal hysterectomy treatment treatment plan

TAH & BSO total abdominal hysterectomy and bilateral

UGI w/SBFT upper gastrointestinal series with small

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(V) VA V/A VAMC VCU VD VDO VDR VDRL VEP Vit Veterans Administration visual acuity Veterans Administration Medical Center voiding cystourethrogram venereal disease vertical dimension of occlusion vertical dime venereal disease research laboratory visual evoked potential vitamin when followed by a specific letter, i.e., Vit. A (W) w/ WAIS-R WBC w/c WD WD/WN Wed W/F W/M WN WNL w/o wt WTR (X) X (Y) y/o yr(s) year old year(s) times, i.e., X2 = 2 times (Z) ZOE ZSM zinc oxide and eugenol zonisamide (Zonegran) with Wechsler Adult Intelligence Scale-Revised white blood count wheelchair well-developed well-developed and well-nourished Wednesday white female white male well-nourished within normal limits without weight within therapeutic range Vol VO VPA VPC V-P VRE VS VSD VSS V Tach volume verbal order valproic acid ventricular premature complexes ventriculo-peritoneal (shunt) vancomycin resistant enterococcus vital signs ventricular septal defect vital signs stable ventricular tachycardia

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SYMBOLS o c s o q degree negative with; together without increase decrease positive less than less than or equal to greater than - use greater than greater than or equal to separates two doses or indicates per as in 5X/D= five times per day x = ( o 1 o 2  re  ? & @ ... except for; with the exception of equal to; equals delta (change) primary secondary check recheck questionable and at therefore

+
< < > > /

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ABCDEFGHIJKLMNOPQRST OVWXYZ

ABBREVIATIONS SYMBOLS

MEDICAL TERMS
Submitted by:

Romatho, Rainida Catherine B. Level 1 Ff

Submitted to:

Ms. Sohaynee Moslem, RN

March 2010

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