Nursing Documentation Abbreviation

AAA

abdominal aortic aneurysm

Abd

abdomen

Ac

before meals

ACLS

advanced cardiac life support

AD

admitting diagnosis or advance directives

A&D

admission and discharge

Ad lib

as desired

ADL

activities of daily living

Adm.

administration

AKA

Above Knee Amputation or Alcoholic Ketoacidosis

ALL

acute lymphocytic leukemia

amb

ambulation

AP or A. P.

appendectomy or anterior/posterior

AV

atrioventricular

BID

twice a day

BKA

below-the-knee amputation (AKA-above)

BLS

basic life support

BM

bowel movement

BP

blood pressure

BPH

benign prostatic hyperplasia

BUN

blood urea nitrogen

BX

biopsy

CABG

coronary artery bypass graft

CAD

coronary artery disease

CBC

complete blood count

CCU

cardiac care unit/coronary care unit

CF

cystic fibrosis

CHF

congestive heart failure

CKD

chronic kidney disease

C/O

complaining of

COPD

chronic obstructive pulmonary disease

CPR

cardiopulmonary resuscitation

C&S

culture and sensitivity

CVA

cerebrovascular accident (stroke)

CVC

central venous catheter

D/C

discontinue or discharge

D&C

dilation and curettage

DI

diabetes insipidus

DIC

disseminated intravascular coagulation

DKA

diabetic ketoacidosis

DM

diabetes mellitus

DVT

deep vein thrombosis

DX

diagnosis

ECG or EKG

electrocardiogram

ED

emergency department

EENT

eyes, ears, nose, throat

ETT

endotracheal tube

FBS

fasting blood sugar

FX

fracture

GI

gastrointestinal

Gtt or G. T. T.

glucose tolerance test

HOB

head of bed

HR

heart rate

HS

bedtime

HX

history

ICU

intensive care unit

I&O

intake and output

LES

lower esophageal sphincter

LMP

last menstrual period

LOC

level of consciousness

LP

lumbar puncture

LPN

licensed practical nurse

LVN

licensed vocational nurse

MAP

mean arterial pressure

MRI

magnetic resonance imaging

MVA

motor vehicle accident

NGT

nasogastric tube

NKA

no known allergies

NPO

nothing by mouth

OA

osteoarthritis

OB

obstetrics

OOB

out of bed

Ortho

orthopedics

OT

occupational therapy

Pc

after meals

PFT

pulmonary function test

PLT

platelets

PRBC

packed red blood cells

Pre-op

before surgery

Prn or p. r. n.

as needed

PT

physical therapy

PTCA

percutaneous transluminal coronary angioplasty

PVC

premature ventricular contraction

RA

rheumatoid arthritis

RBC

red blood cell (s)

RN

registered nurse

Rom/ R. O. M.

range of motion

RT

Respiratory Therapist or Respiratory Therapy

SBAR

Situation, Background, Assessment, Recommendation/Request

SIADH

syndrome of inappropriate antidiuretic hormone secretion

SLE

systemic lupus erythematosus

SOB

shortness of breath

SSE or S. S. E.

soap suds enema

STAT

immediately, at once

STD

sexually transmitted disease

TB

tuberculosis

TIA

transient ischemic attack

Tid

three times a day

TPN

total parenteral nutrition

T&S

type and screen