Summary

This document provides a list of medical abbreviations and their meanings, commonly used in healthcare documentation. It includes various abbreviations for measurements, treatments, and diagnoses, including those used in medical records and note-taking.

Full Transcript

A or Ax - Axillary ( armpit temperature) AROM - Active Range of Motion ( Range of motion exercises that the resident does by themself) a.c. - Before Meals (Abbreviation for prescription before meals.) ADL - Activities of Daily Living (Common hygiene practices) Ad lib - At Liberty ( when the resi...

A or Ax - Axillary ( armpit temperature) AROM - Active Range of Motion ( Range of motion exercises that the resident does by themself) a.c. - Before Meals (Abbreviation for prescription before meals.) ADL - Activities of Daily Living (Common hygiene practices) Ad lib - At Liberty ( when the resident is not to eat certain food but can have as much as they want for their foods) AEB - As evidence by ( document evidence or proof of an even or conduction) A.M - Midnight to noon B&B - Bowel and Bladder program (provides a plan of helping resident to the bathroom periodically) b. i. d - Twitch a day ( taking prescription twitch a day or other stuff) BKA - Below knee Amputation ( Amputation below the knee) BM - bowel movement BP - blood pressure BRP - Bathroom privileges ( A resident who is on bedrest and has bathroom privileges in account to their pattern to ambulate.) C - With ( A c with line above it means come) C.C Cubic Centimeter C/O - Complains of (Abbreviation used when documenting a resident symptoms) CVA - Cerebrovascular Accident ( Stroke) occurs when there is interference with blood flow to the brain. CMS - Circulation (color), motion, sensitivity (An assessment of the vascular and neurological health of the body) DTA - Diet as tolerated (Advancing the diet as the resident can tolerates usually after surgery) DNR - Do not resuscitate (a written order by a doctor that states no resuscitation to a resident) h/hr - hour H2O - Water HOB - Head of bed (Abbreviation usually followed by the number of degrees of elevation.) HOH - hard of hearing (Resident that have a hard time hearing) H.s. - Bedtime / hours of sleep Ht - height ( The height of a resident) I & O - Intake and output ( Intake - All liquid consumed by the resident Output - Liquids that leave the body. MI - Myocardial infarction aka heart attack (Occurs when a portion of the heart is deprived of oxygen caused by blockage.) Na - Sodium NKA - No known Allergies (When the resident does not have any known allergies to food or medications.) NPO - Nothing by mouth ( Withhold food and or fluids) PO - Oral ( by mouth) O2 - Oxygen OT - Occupation Therapy ( helps residents partake in tasks or activities that they want or need to do as part of their lives.) Oz - Ounce ( A unit of volume 1 oz = 30 c.c or 30 mL) P.c. - After meals ( used when a resident needs to take medications or other stuff after a meal.) Peri - Perineal ( Cleaning of the genital groin, and rectal area.) PM - 12 noon to Night PT - Physical Therapy ( The goal of such therapy is to restore, metain, and or promote optimal physical function) P.r.n - As needed ( A resident taking a medication as needed for certain saturation) PROM - Passive Range of motion ( Exercising the resident joints when they are unable to do so themself) Px - Physical examination (A poutine test the doctors perform to check the overall health) q - every q.d - Every day q.h - every hour q.4.h - every 4 hour q.i.d - 4 times per day R - Rectal (rectal temperature) Rt - right SBA - Stand by Assist Sx - Symptoms ( Signs of an illness) S with line on top - Without (w/o) SOB - Shortness of breath (Difficulty breathing also referred to as dyspnea) Stat - immediately TC & DB - Turn cough and Deep breath (Abbreviation often use after surgery to help breathing, clear lungs and prevent pneumonia) T.i.d - Three times per day TPR - Temperature pulse and respiration - (Record vitals as such T 98.6 P 80, R20) Tx - Treatment VS - vital sign W/C - Wheelchair Wt - weight ⬅/ - less than or greater than

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