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AMB
Ambulatory
BRP
Bathroom Privileges
CBR
Complete bed rest
OOB
Out of Bed
Up ad lib
Up as desired
abd
abdomen
BP
Blood pressure
C
Celsius
C/O
Complains of
CTA
Clear to auscultation
Dx
Diagnosis
F
Fahrenheit
GI
Gastrointestinal
GU
Genitourinary
H/A or HA
Headache
h/o
History of
HPI
History of present illness
It or I
Left
MAE
Moves all extremities
NAD
No apparent distress
NKA
No known allergies
NKDA
No known drug allergies
N/V
Nausea and Vomiting
neg
Negative
P
Pulse
PE
physical examination
PHM
Past medical history
R
respirations
R/O
Rule out
ROS
Review of systems
rt or r
right
SOB
Short of breath
Sx
Symptoms
T
Temperature
Tx
treatment
⊕
Positive
Θ
negative
BPH
Benign prostatic hypertrophy or hyperplasia
CA
Cancer
CABG
Coronary artery bypass graft
CAD
Coronary Artery disease
CHF
Congestive heart failure
COPD
Chronic obstructive pulmonary disease
CVA
Cerebrovascular accident
DM
Diabetes Mellitus
HTN
Hypertension
MI
Myocardial infarction
PE
Pulmonary emboli
PVD
Peripheral vascular disease
STD
Sexually transmitted disease
STI
Sexually Transmitted Infection
URI
Upper respiratory infection
UTI
Urinary Tract infection
ABG
Arterial blood gases
CBC
Complete blood count
C&S
Culture and sensitivity
CXR
Chest X-ray
ECG (EKG)
Electrocaridogram
UA
Urinalysis
RBC
Red blood cells
WBC
White blood cell
HOB
Head of bed
BM
Bowel movement
AMA
against medical advice
IM
Intramuscular
IV
Intravenous
KVO
Keep vein open
I&O
Intake and output
NG
Nasogastric
noc
night
NPO
Nothing by mouth
NS
Normal saline
PRN
as needed
ROM
Range of motion
RX
Prescription
S/P
Status post
STAT
Immediately
Subcue
subcutaneous
TF
Tube feeding
TX
treatment
x
times
SOAP
Subjective, Objective, assesment, Plan
PIE
Problem, Intervention, Evaluation
WDL
Within Defined limits
EMR
Electronic medical record
AIRA
Assesment, intervention, response, action
DARA
Data, action, response, action
BID
Twice a day
ā
Before
C~
With
P~
After
S~
Without
U,u (unit)
Do not use; write unit
IU (international unit
Do not use; write out
Q.D, QD,a.d, ad(daily)
Do not use (just write out daily)
Q.O.D, QOD, g.o.d, god (every other day)
Do not use ( write out every other day)
Lack of leading zero (.Xmg)
Do not use (write out 0.X mg
MS
Do not use (write out Morphine sulfate)
MSO4 and MgSO4
Do not use (write magnesium sulfate)
Trailing zero (X.0 mg)
Do not use (write as X mg