| ABG | Arterial Blood Gas | Blood test measuring oxygen, carbon dioxide, and pH levels in arterial blood | diagnostics |
| AC | Before Meals (Ante Cibum) | Medication timing instruction indicating administration before eating | medications |
| ACE | Angiotensin-Converting Enzyme | Class of drugs used to treat hypertension and heart failure | medications |
| ACLS | Advanced Cardiac Life Support | Advanced resuscitation protocols for cardiac emergencies | procedures |
| ACS | Acute Coronary Syndrome | Umbrella term for conditions caused by sudden reduced blood flow to the heart | diagnoses |
| ADH | Antidiuretic Hormone | Hormone that regulates water balance and blood pressure | lab-values |
| ADL | Activities of Daily Living | Basic self-care tasks including bathing, dressing, eating, and toileting | assessments |
| AED | Automated External Defibrillator | Portable device that checks heart rhythm and delivers a shock if needed | procedures |
| AFib | Atrial Fibrillation | Irregular and often rapid heart rhythm originating in the atria | diagnoses |
| AKA | Above-Knee Amputation | Surgical removal of the leg above the knee joint | procedures |
| AKI | Acute Kidney Injury | Sudden episode of kidney failure or kidney damage occurring over hours to days | diagnoses |
| ALP | Alkaline Phosphatase | Enzyme found in liver and bones; elevated levels may indicate liver disease | lab-values |
| ALS | Amyotrophic Lateral Sclerosis | Progressive neurodegenerative disease affecting motor neurons | diagnoses |
| ALT | Alanine Aminotransferase | Liver enzyme used to detect liver damage; part of liver function tests | lab-values |
| AMA | Against Medical Advice | Patient's decision to leave a healthcare facility without physician approval | charting |
| AMI | Acute Myocardial Infarction | Heart attack caused by blocked blood flow to the heart muscle | diagnoses |
| AMS | Altered Mental Status | Change in cognitive function including confusion, disorientation, or decreased consciousness | assessments |
| AP | Anteroposterior | Direction of X-ray beam from front to back of the patient | diagnostics |
| APGAR | Appearance, Pulse, Grimace, Activity, Respiration | Scoring system used to assess newborn health at 1 and 5 minutes after birth | assessments |
| aPTT | Activated Partial Thromboplastin Time | Blood test measuring how long it takes blood to clot; monitors heparin therapy | lab-values |
| ARDS | Acute Respiratory Distress Syndrome | Life-threatening lung condition causing severe shortness of breath and low blood oxygen | diagnoses |
| ARF | Acute Renal Failure | Sudden loss of kidney function; also called acute kidney injury | diagnoses |
| ASA | Aspirin (Acetylsalicylic Acid) | Common analgesic and antiplatelet medication used in cardiac patients | medications |
| ASAP | As Soon As Possible | Priority designation for urgent orders or tasks | general |
| AST | Aspartate Aminotransferase | Enzyme found in liver and heart; elevated levels may indicate tissue damage | lab-values |
| AV | Atrioventricular | Relating to the atria and ventricles of the heart | vitals |
| AVF | Arteriovenous Fistula | Surgical connection between an artery and vein, commonly for dialysis access | procedures |
| AVM | Arteriovenous Malformation | Abnormal tangle of blood vessels connecting arteries and veins | diagnoses |
| AVSS | Afebrile, Vital Signs Stable | Documentation shorthand indicating no fever and stable vital signs | charting |
| BID | Twice a Day (Bis in Die) | Medication frequency indicating two doses per day | medications |
| BiPAP | Bilevel Positive Airway Pressure | Non-invasive ventilation providing two levels of air pressure | procedures |
| BKA | Below-Knee Amputation | Surgical removal of the leg below the knee joint | procedures |
| BLE | Bilateral Lower Extremities | Both legs; used in assessment documentation | charting |
| BLS | Basic Life Support | Emergency cardiovascular care including CPR and AED use | procedures |
| BM | Bowel Movement | Documentation of a patient's stool output | charting |
| BMI | Body Mass Index | Measurement of body fat based on height and weight | assessments |
| BMP | Basic Metabolic Panel | Blood test measuring glucose, calcium, electrolytes, and kidney function | lab-values |
| BNP | B-type Natriuretic Peptide | Blood test used to diagnose and monitor heart failure | lab-values |
| BP | Blood Pressure | Force of blood pushing against artery walls, measured in mmHg | vitals |
| BPH | Benign Prostatic Hyperplasia | Non-cancerous enlargement of the prostate gland | diagnoses |
| BPM | Beats Per Minute | Unit measuring heart rate | vitals |
| BRP | Bathroom Privileges | Order allowing a patient to use the bathroom | general |
| BS | Blood Sugar / Bowel Sounds | Blood glucose level or auscultated abdominal sounds depending on context | assessments |
| BSA | Body Surface Area | Measurement used for medication dosing and burn assessment | assessments |
| BUE | Bilateral Upper Extremities | Both arms; used in assessment documentation | charting |
| BUN | Blood Urea Nitrogen | Blood test measuring kidney function and protein metabolism | lab-values |
| Bx | Biopsy | Removal of tissue for examination under a microscope | procedures |
| C&S | Culture and Sensitivity | Lab test identifying bacteria and which antibiotics will be effective | diagnostics |
| Ca | Calcium | Electrolyte essential for bone health, muscle function, and nerve signaling | lab-values |
| CABG | Coronary Artery Bypass Graft | Open-heart surgery to restore blood flow to the heart | procedures |
| CAD | Coronary Artery Disease | Narrowing of the coronary arteries due to plaque buildup | diagnoses |
| CAM | Confusion Assessment Method | Validated tool for identifying delirium in hospitalized patients | assessments |
| CBC | Complete Blood Count | Blood test measuring red cells, white cells, hemoglobin, hematocrit, and platelets | lab-values |
| CBG | Capillary Blood Glucose | Fingerstick blood sugar test used for quick glucose monitoring | diagnostics |
| CC | Chief Complaint | The primary reason a patient seeks medical care | charting |
| CCU | Coronary Care Unit / Critical Care Unit | Specialized hospital unit for patients with serious heart conditions | general |
| CHF | Congestive Heart Failure | Chronic condition where the heart cannot pump blood efficiently | diagnoses |
| CI | Cardiac Index | Cardiac output adjusted for body surface area | vitals |
| CKD | Chronic Kidney Disease | Progressive loss of kidney function over months or years | diagnoses |
| Cl | Chloride | Electrolyte important for fluid balance and digestion | lab-values |
| CMP | Comprehensive Metabolic Panel | Blood test including BMP plus liver function tests and protein levels | lab-values |
| CMS | Circulation, Motion, Sensation | Neurovascular assessment performed on extremities | assessments |
| CN | Cranial Nerve | Twelve pairs of nerves originating from the brain assessed in neurological exams | assessments |
| CNS | Central Nervous System | The brain and spinal cord | general |
| CO | Cardiac Output | Volume of blood pumped by the heart per minute | vitals |
| CO2 | Carbon Dioxide | Gas measured in ABGs and metabolic panels to assess acid-base balance | lab-values |
| COPD | Chronic Obstructive Pulmonary Disease | Chronic inflammatory lung disease causing obstructed airflow | diagnoses |
| CPAP | Continuous Positive Airway Pressure | Non-invasive ventilation delivering constant air pressure to keep airways open | procedures |
| CPK | Creatine Phosphokinase | Enzyme released when muscles are damaged; elevated in MI and rhabdomyolysis | lab-values |
| CPR | Cardiopulmonary Resuscitation | Emergency procedure combining chest compressions and rescue breathing | procedures |
| CRP | C-Reactive Protein | Blood marker of inflammation; elevated in infection and autoimmune conditions | lab-values |
| CRRT | Continuous Renal Replacement Therapy | Slow, continuous form of dialysis used in critically ill patients | procedures |
| CSF | Cerebrospinal Fluid | Fluid surrounding the brain and spinal cord; analyzed via lumbar puncture | diagnostics |
| CT | Computed Tomography | Imaging technique using X-rays to create cross-sectional images of the body | diagnostics |
| CTA | CT Angiography | CT scan with contrast to visualize blood vessels | diagnostics |
| CVA | Cerebrovascular Accident (Stroke) | Interruption of blood supply to the brain causing tissue death | diagnoses |
| CVC | Central Venous Catheter | Catheter placed in a large vein for medication delivery or hemodynamic monitoring | procedures |
| CVL | Central Venous Line | IV line inserted into a large central vein such as the jugular or subclavian | procedures |
| CVP | Central Venous Pressure | Measurement of blood pressure in the vena cava near the right atrium | vitals |
| CXR | Chest X-Ray | Radiographic image of the chest to evaluate lungs, heart, and thoracic structures | diagnostics |
| D5W | 5% Dextrose in Water | IV solution providing free water and calories | medications |
| D50 | 50% Dextrose | Concentrated glucose solution for treating severe hypoglycemia | medications |
| DAR | Data, Action, Response | Nursing documentation format used in focus charting | charting |
| DBP | Diastolic Blood Pressure | Pressure in arteries when the heart rests between beats | vitals |
| DC | Discontinue / Discharge Error-prone (ISMP) | Order to stop a treatment or release a patient from care. D/C is on the ISMP error-prone list because medications on a discharge list marked D/C have been stopped in error. Write "discharge" or "discontinue" in full | charting |
| DI | Diabetes Insipidus | Condition causing excessive thirst and large amounts of dilute urine | diagnoses |
| DIC | Disseminated Intravascular Coagulation | Life-threatening condition with abnormal clotting throughout blood vessels | diagnoses |
| DKA | Diabetic Ketoacidosis | Serious diabetic complication with high blood sugar, ketones, and acidosis | diagnoses |
| DM | Diabetes Mellitus | Metabolic disease characterized by high blood sugar levels | diagnoses |
| DNI | Do Not Intubate | Advance directive stating the patient should not be placed on a ventilator | general |
| DNR | Do Not Resuscitate | Advance directive stating CPR should not be performed | general |
| DOA | Dead on Arrival | Patient found without signs of life upon EMS or hospital arrival | charting |
| DOB | Date of Birth | Patient identifier used for verification and records | charting |
| DOE | Dyspnea on Exertion | Shortness of breath triggered by physical activity | assessments |
| DPT | Diphtheria, Pertussis, Tetanus | Combination vaccine protecting against three bacterial diseases | medications |
| DRE | Digital Rectal Exam | Physical examination of the rectum using a gloved finger | procedures |
| DSD | Dry Sterile Dressing | Wound covering applied under sterile technique | procedures |
| DTR | Deep Tendon Reflexes | Involuntary muscle response tested during neurological examination | assessments |
| DVT | Deep Vein Thrombosis | Blood clot forming in a deep vein, usually in the legs | diagnoses |
| Dx | Diagnosis | The identified medical condition or disease | charting |
| EBL | Estimated Blood Loss | Approximate amount of blood lost during surgery or trauma | procedures |
| ECG | Electrocardiogram | Test recording electrical activity of the heart; also abbreviated EKG | diagnostics |
| ECHO | Echocardiogram | Ultrasound of the heart to evaluate structure and function | diagnostics |
| ECMO | Extracorporeal Membrane Oxygenation | Life support technique providing prolonged cardiac and respiratory support | procedures |
| ED | Emergency Department | Hospital department providing immediate care for acute injuries and illnesses | general |
| EEG | Electroencephalogram | Test measuring electrical activity in the brain | diagnostics |
| EF | Ejection Fraction | Percentage of blood pumped out of the heart with each contraction | diagnostics |
| EKG | Electrocardiogram | Test recording the heart's electrical activity via electrodes on the skin | diagnostics |
| EMG | Electromyography | Test measuring muscle electrical activity to diagnose neuromuscular disorders | diagnostics |
| EMS | Emergency Medical Services | System providing emergency medical care and transport | general |
| EMT | Emergency Medical Technician | Pre-hospital emergency care provider | general |
| ENT | Ear, Nose, and Throat | Medical specialty also known as otolaryngology | general |
| EPS | Extrapyramidal Symptoms | Drug-induced movement disorders often caused by antipsychotic medications | assessments |
| ER | Emergency Room | Hospital area for emergency treatment; also called the ED | general |
| ERCP | Endoscopic Retrograde Cholangiopancreatography | Procedure combining endoscopy and X-rays to treat bile duct problems | procedures |
| ESR | Erythrocyte Sedimentation Rate | Blood test measuring inflammation by how fast red blood cells settle | lab-values |
| ESRD | End-Stage Renal Disease | Final stage of chronic kidney disease requiring dialysis or transplant | diagnoses |
| ET | Endotracheal | Relating to a tube placed in the trachea for mechanical ventilation | procedures |
| ETT | Endotracheal Tube | Tube inserted through the mouth into the trachea to maintain an airway | procedures |
| ETOH | Ethanol (Alcohol) | Medical shorthand for alcohol, often used in toxicology and history taking | general |
| EVD | External Ventricular Drain | Device draining cerebrospinal fluid from the brain's ventricles | procedures |
| FBS | Fasting Blood Sugar | Blood glucose measurement taken after an overnight fast | lab-values |
| FHR | Fetal Heart Rate | Heart rate of the unborn baby, normally 110-160 BPM | vitals |
| FiO2 | Fraction of Inspired Oxygen | Percentage of oxygen in the air mixture a patient is breathing | vitals |
| FSBG | Fingerstick Blood Glucose | Point-of-care blood sugar test using a fingertip blood sample | diagnostics |
| FULL CODE | Full Resuscitation Status | All life-saving measures should be performed including CPR and intubation | general |
| FUO | Fever of Unknown Origin | Elevated temperature lasting more than 3 weeks without identified cause | diagnoses |
| Fx | Fracture | A break in a bone | diagnoses |
| GCS | Glasgow Coma Scale | Neurological scale measuring consciousness based on eye, verbal, and motor responses | assessments |
| GERD | Gastroesophageal Reflux Disease | Chronic condition where stomach acid flows back into the esophagus | diagnoses |
| GFR | Glomerular Filtration Rate | Measure of kidney function indicating how well kidneys filter blood | lab-values |
| GI | Gastrointestinal | Relating to the stomach and intestines | general |
| gtt | Drops (Guttae) | Latin abbreviation for drops; used in medication orders | medications |
| GTT | Glucose Tolerance Test | Test measuring the body's ability to process glucose; screens for diabetes | diagnostics |
| G-tube | Gastrostomy Tube | Feeding tube inserted directly into the stomach through the abdominal wall | procedures |
| GU | Genitourinary | Relating to the genital and urinary organs | general |
| HA | Headache | Pain in any region of the head | assessments |
| Hb | Hemoglobin | Protein in red blood cells that carries oxygen throughout the body | lab-values |
| HbA1c | Glycated Hemoglobin | Blood test showing average blood sugar levels over the past 2-3 months | lab-values |
| HCG | Human Chorionic Gonadotropin | Hormone measured in pregnancy tests; produced by the placenta | lab-values |
| HCO3 | Bicarbonate | Buffer in the blood that helps maintain acid-base balance | lab-values |
| Hct | Hematocrit | Percentage of red blood cells in the total blood volume | lab-values |
| HD | Hemodialysis | Procedure filtering waste and excess fluid from the blood using a machine | procedures |
| HDL | High-Density Lipoprotein | Good cholesterol that helps remove other forms of cholesterol from the blood | lab-values |
| HEENT | Head, Eyes, Ears, Nose, Throat | Physical examination of the head and sensory organs | assessments |
| HF | Heart Failure | Condition where the heart cannot pump blood effectively to meet the body's needs | diagnoses |
| HgB | Hemoglobin | Alternate abbreviation for hemoglobin in blood tests | lab-values |
| HIPAA | Health Insurance Portability and Accountability Act | Federal law protecting the privacy and security of patient health information | general |
| HIV | Human Immunodeficiency Virus | Virus attacking the immune system that can lead to AIDS if untreated | diagnoses |
| HIT | Heparin-Induced Thrombocytopenia | Serious complication where heparin causes dangerous drop in platelet count | diagnoses |
| HOB | Head of Bed | Position of the upper portion of the hospital bed; often elevated 30-45 degrees | general |
| HR | Heart Rate | Number of heartbeats per minute | vitals |
| HS | At Bedtime (Hora Somni) | Medication timing instruction indicating administration at bedtime | medications |
| HTN | Hypertension | High blood pressure; the 2017 ACC/AHA guideline defines it as systolic 130 mmHg or higher or diastolic 80 mmHg or higher | diagnoses |
| Hx | History | Patient's medical history or history of present illness | charting |
| I&D | Incision and Drainage | Procedure to drain an abscess by making a cut in the skin | procedures |
| I&O | Intake and Output | Measurement of all fluids consumed and excreted over a specific period | assessments |
| IABP | Intra-Aortic Balloon Pump | Mechanical device helping the heart pump blood in cardiogenic shock | procedures |
| IBD | Inflammatory Bowel Disease | Chronic inflammation of the GI tract including Crohn's disease and ulcerative colitis | diagnoses |
| IBS | Irritable Bowel Syndrome | Chronic functional GI disorder with abdominal pain and altered bowel habits | diagnoses |
| ICD | Implantable Cardioverter-Defibrillator | Device implanted in the chest to detect and correct abnormal heart rhythms | procedures |
| ICP | Intracranial Pressure | Pressure inside the skull; elevated ICP is a neurological emergency | vitals |
| ICU | Intensive Care Unit | Hospital unit for critically ill patients requiring close monitoring | general |
| IM | Intramuscular | Injection route delivering medication into muscle tissue | medications |
| INR | International Normalized Ratio | Blood test measuring clotting time; used to monitor warfarin therapy | lab-values |
| IO | Intraosseous | Emergency access route delivering fluids and medications into bone marrow | medications |
| IPC | Intermittent Pneumatic Compression | Inflatable leg devices preventing blood clots in hospitalized patients | procedures |
| IPPB | Intermittent Positive Pressure Breathing | Respiratory treatment delivering aerosolized medication under pressure | procedures |
| IS | Incentive Spirometry | Breathing device encouraging deep breaths to prevent lung complications | procedures |
| IUD | Intrauterine Device | Contraceptive device placed inside the uterus | procedures |
| IV | Intravenous | Route delivering fluids or medications directly into a vein | medications |
| IVF | Intravenous Fluids | Fluids administered directly into a vein for hydration or medication delivery | medications |
| IVP | Intravenous Push | Method of giving medication through an IV line rapidly via syringe | medications |
| IVPB | Intravenous Piggyback | Secondary IV bag connected to the primary line for intermittent medication delivery | medications |
| J-tube | Jejunostomy Tube | Feeding tube inserted directly into the jejunum through the abdominal wall | procedures |
| JVD | Jugular Venous Distension | Visible bulging of the jugular veins indicating elevated right heart pressure | assessments |
| K | Potassium | Electrolyte critical for heart rhythm, muscle contraction, and nerve function | lab-values |
| KCl | Potassium Chloride | Electrolyte replacement supplement for hypokalemia | medications |
| kg | Kilogram | Metric unit of weight used for medication dosing calculations | general |
| KUB | Kidneys, Ureters, Bladder | Abdominal X-ray focused on the urinary tract | diagnostics |
| KVO | Keep Vein Open | Minimal IV flow rate to maintain line patency | medications |
| L | Liter | Metric unit of volume used in fluid measurements | general |
| L&D | Labor and Delivery | Hospital unit where babies are born | general |
| LAD | Left Anterior Descending | Coronary artery supplying the front and left side of the heart | general |
| LDH | Lactate Dehydrogenase | Enzyme released when tissue is damaged; elevated in many conditions | lab-values |
| LDL | Low-Density Lipoprotein | Bad cholesterol that builds up in artery walls | lab-values |
| LFTs | Liver Function Tests | Panel of blood tests assessing liver health including ALT, AST, ALP, bilirubin | lab-values |
| LLL | Left Lower Lobe | Lower section of the left lung | assessments |
| LLQ | Left Lower Quadrant | Lower left section of the abdomen | assessments |
| LMP | Last Menstrual Period | Date of the first day of the most recent menstrual cycle | assessments |
| LOC | Level of Consciousness | Patient's state of awareness ranging from alert to comatose | assessments |
| LP | Lumbar Puncture | Procedure inserting a needle into the spinal canal to collect cerebrospinal fluid | procedures |
| LR | Lactated Ringer's | IV solution containing sodium, potassium, calcium, and lactate for fluid resuscitation | medications |
| LUL | Left Upper Lobe | Upper section of the left lung | assessments |
| LUQ | Left Upper Quadrant | Upper left section of the abdomen | assessments |
| LVH | Left Ventricular Hypertrophy | Thickening of the heart's left ventricle wall, often from chronic hypertension | diagnoses |
| MAP | Mean Arterial Pressure | Average arterial pressure during a single cardiac cycle; the usual target in sepsis and shock is 65 mmHg or higher | vitals |
| MAR | Medication Administration Record | Document tracking all medications given to a patient | charting |
| mcg | Microgram | Unit of measurement equal to one-millionth of a gram | medications |
| MD | Medical Doctor | Physician with a Doctor of Medicine degree | general |
| MDI | Metered-Dose Inhaler | Handheld device delivering a specific amount of medication to the lungs | medications |
| mEq | Milliequivalent | Unit measuring the chemical activity of electrolytes | medications |
| MEWS | Modified Early Warning Score | Scoring system detecting clinical deterioration using vital signs | assessments |
| Mg | Magnesium | Electrolyte important for muscle and nerve function, heart rhythm, and bone strength | lab-values |
| mg | Milligram | Unit of measurement equal to one-thousandth of a gram | medications |
| MI | Myocardial Infarction | Heart attack caused by blocked blood flow damaging heart muscle | diagnoses |
| MIDLINE | Midline Catheter | Peripheral IV catheter 8-20 cm long inserted in the upper arm | procedures |
| mL | Milliliter | Unit of volume equal to one-thousandth of a liter | general |
| MMR | Measles, Mumps, Rubella | Combination vaccine protecting against three viral diseases | medications |
| MoA | Mechanism of Action | How a drug produces its pharmacological effect | medications |
| MRA | Magnetic Resonance Angiography | MRI technique used to visualize blood vessels | diagnostics |
| MRI | Magnetic Resonance Imaging | Imaging technique using magnetic fields and radio waves for detailed body images | diagnostics |
| MRSA | Methicillin-Resistant Staphylococcus Aureus | Antibiotic-resistant bacterial infection requiring special precautions | diagnoses |
| MS | Multiple Sclerosis / Morphine Sulfate Do not use (Joint Commission) | Multiple sclerosis is an autoimmune disease of the CNS. As a drug abbreviation, MS (like MSO4 and MgSO4) is on The Joint Commission's Do Not Use list because it can mean morphine sulfate or magnesium sulfate: write the drug name in full | diagnoses |
| MVA | Motor Vehicle Accident | Collision involving a motor vehicle; common cause of trauma admissions | charting |
| Na | Sodium | Electrolyte essential for fluid balance, nerve function, and muscle contraction | lab-values |
| NaCl | Sodium Chloride | Salt compound used in IV solutions; 0.9% NaCl is normal saline, used for fluid replacement and medication dilution | medications |
| NAD | No Acute Distress / No Apparent Distress | Assessment finding indicating patient appears comfortable | charting |
| NANDA | North American Nursing Diagnosis Association | Organization developing standardized nursing diagnoses | charting |
| NAS | Neonatal Abstinence Syndrome | Withdrawal symptoms in newborns exposed to substances in utero | diagnoses |
| NC | Nasal Cannula | Device delivering supplemental oxygen through two nasal prongs | procedures |
| NEB | Nebulizer | Device converting liquid medication into a mist for inhalation | medications |
| NEWS | National Early Warning Score | Standardized system for assessing acute illness severity using vital signs | assessments |
| NG | Nasogastric | Tube inserted through the nose into the stomach for feeding or decompression | procedures |
| NGT | Nasogastric Tube | Tube passed through the nose to the stomach for drainage or feeding | procedures |
| NICU | Neonatal Intensive Care Unit | Hospital unit providing specialized care for critically ill newborns | general |
| NIHSS | National Institutes of Health Stroke Scale | Standardized assessment tool quantifying stroke severity | assessments |
| NKA | No Known Allergies | Documentation indicating patient has no known allergies | charting |
| NKDA | No Known Drug Allergies | Documentation indicating patient has no known medication allergies | charting |
| NMS | Neuroleptic Malignant Syndrome | Life-threatening reaction to antipsychotic medications | diagnoses |
| NP | Nurse Practitioner | Advanced practice registered nurse with prescriptive authority | general |
| NPA | Nasopharyngeal Airway | Soft rubber tube inserted through the nose to maintain an open airway | procedures |
| NPO | Nothing by Mouth (Nil Per Os) | Order restricting all oral intake including food, drink, and medications | general |
| NRB | Non-Rebreather Mask | Oxygen mask with a reservoir bag delivering high-concentration oxygen, roughly 60-90% FiO2 at 10-15 L/min depending on mask fit | procedures |
| NS | Normal Saline (0.9% NaCl) | Isotonic IV solution used for fluid resuscitation and medication dilution | medications |
| NSAID | Non-Steroidal Anti-Inflammatory Drug | Class of medications reducing pain, inflammation, and fever | medications |
| NSR | Normal Sinus Rhythm | Normal heart rhythm originating from the sinoatrial node | vitals |
| NTG | Nitroglycerin | Vasodilator medication used to treat angina and heart failure | medications |
| NWB | Non-Weight Bearing | Restriction preventing the patient from placing weight on an extremity | general |
| O2 | Oxygen | Gas essential for cellular respiration delivered as supplemental therapy | vitals |
| O2 sat | Oxygen Saturation | Percentage of hemoglobin carrying oxygen; normal range 95-100% | vitals |
| OB | Obstetrics | Medical specialty focused on pregnancy, childbirth, and postpartum care | general |
| OD | Overdose / Right Eye (Oculus Dexter) Error-prone (ISMP) | Excessive drug ingestion, or right eye in ophthalmic documentation. On the ISMP error-prone list: OD (right eye) is confused with AD (right ear), and OD meaning once daily has led to oral liquids being given in the eye. Write "right eye" or "daily" in full | general |
| OOB | Out of Bed | Patient activity order allowing or requiring ambulation | general |
| OPA | Oropharyngeal Airway | Device inserted through the mouth to maintain an open airway in unconscious patients | procedures |
| OR | Operating Room | Sterile hospital room where surgical procedures are performed | general |
| ORIF | Open Reduction Internal Fixation | Surgery to repair a broken bone using plates, screws, or rods | procedures |
| OS | Left Eye (Oculus Sinister) Error-prone (ISMP) | Ophthalmic abbreviation for the left eye. On the ISMP error-prone list because it is confused with AS (left ear). Write "left eye" instead | general |
| OT | Occupational Therapy | Therapy helping patients perform daily activities after illness or injury | general |
| OU | Both Eyes (Oculi Uterque) Error-prone (ISMP) | Ophthalmic abbreviation for both eyes. On the ISMP error-prone list because it is confused with AU (each ear). Write "each eye" instead | general |
| PA | Posteroanterior / Physician Assistant | X-ray direction from back to front, or a mid-level healthcare provider | general |
| PAC | Premature Atrial Contraction | Early heartbeat originating in the atria | vitals |
| PACU | Post-Anesthesia Care Unit | Recovery area where patients are monitored after surgery | general |
| PaO2 | Partial Pressure of Arterial Oxygen | ABG value measuring oxygen dissolved in arterial blood; normal 80-100 mmHg | lab-values |
| PaCO2 | Partial Pressure of Arterial Carbon Dioxide | ABG value measuring CO2 in arterial blood; normal 35-45 mmHg | lab-values |
| PC | After Meals (Post Cibum) | Medication timing instruction indicating administration after eating | medications |
| PCA | Patient-Controlled Analgesia | Pump system allowing patients to self-administer pain medication | medications |
| PCN | Penicillin | Antibiotic used to treat bacterial infections | medications |
| PD | Peritoneal Dialysis | Dialysis method using the abdominal lining to filter blood | procedures |
| PE | Pulmonary Embolism | Blood clot blocking an artery in the lungs; life-threatening emergency | diagnoses |
| PEA | Pulseless Electrical Activity | Cardiac arrest rhythm showing electrical activity but no pulse | diagnoses |
| PEARL | Pupils Equal And Reactive to Light | Normal neurological finding during pupil assessment | assessments |
| PEEP | Positive End-Expiratory Pressure | Ventilator setting maintaining pressure in lungs at end of expiration | procedures |
| PEG | Percutaneous Endoscopic Gastrostomy | Procedure placing a feeding tube directly into the stomach through the skin | procedures |
| PERRLA | Pupils Equal, Round, Reactive to Light and Accommodation | Normal neurological finding indicating healthy pupillary response | assessments |
| PFT | Pulmonary Function Test | Group of tests measuring lung capacity and airflow | diagnostics |
| pH | Power of Hydrogen | Measure of acidity or alkalinity; normal blood pH is 7.35-7.45 | lab-values |
| PICC | Peripherally Inserted Central Catheter | Long IV line inserted in the arm and threaded to a large vein near the heart | procedures |
| PID | Pelvic Inflammatory Disease | Infection of the female reproductive organs, often from STIs | diagnoses |
| PIV | Peripheral Intravenous | Standard IV catheter inserted into a peripheral vein in the hand or arm | procedures |
| PMH | Past Medical History | Record of patient's previous illnesses, surgeries, and medical conditions | charting |
| PNA | Pneumonia | Infection causing inflammation of the air sacs in one or both lungs | diagnoses |
| PNS | Peripheral Nervous System | Nerves outside the brain and spinal cord | general |
| PO | By Mouth (Per Os) | Medication route indicating oral administration | medications |
| POC | Point of Care | Testing performed at or near the patient's bedside | diagnostics |
| POLST | Physician Orders for Life-Sustaining Treatment | Medical order documenting patient wishes for end-of-life care | general |
| POST-OP | After Surgery (Postoperative) | Period following a surgical procedure | charting |
| PPD | Purified Protein Derivative | Tuberculosis skin test injected intradermally to check for TB exposure | diagnostics |
| PPE | Personal Protective Equipment | Equipment worn to minimize exposure to hazards including gloves, gowns, and masks | general |
| PPI | Proton Pump Inhibitor | Class of drugs reducing stomach acid production for GERD and ulcers | medications |
| PR | Per Rectum | Medication route indicating rectal administration | medications |
| PRE-OP | Before Surgery (Preoperative) | Period before a surgical procedure | charting |
| PRN | As Needed (Pro Re Nata) | Medication order allowing administration when the patient needs it | medications |
| PSA | Prostate-Specific Antigen | Blood test screening for prostate cancer; elevated levels may indicate disease | lab-values |
| PT | Prothrombin Time / Physical Therapy | Blood clotting test or rehabilitation service depending on context | lab-values |
| PTCA | Percutaneous Transluminal Coronary Angioplasty | Procedure using a balloon to open narrowed coronary arteries | procedures |
| PTH | Parathyroid Hormone | Hormone regulating calcium and phosphorus levels in the blood | lab-values |
| PTSD | Post-Traumatic Stress Disorder | Mental health condition triggered by experiencing or witnessing a traumatic event | diagnoses |
| PTT | Partial Thromboplastin Time | Blood test measuring the time it takes for blood to clot | lab-values |
| PUD | Peptic Ulcer Disease | Open sores in the lining of the stomach or duodenum | diagnoses |
| PVC | Premature Ventricular Contraction | Early heartbeat originating in the ventricles | vitals |
| PVD | Peripheral Vascular Disease | Circulatory condition causing narrowed blood vessels outside the heart and brain | diagnoses |
| PVR | Post-Void Residual | Amount of urine remaining in the bladder after urination | assessments |
| Px | Physical Examination / Prognosis | Systematic assessment of a patient's body, or the expected course of a disease, depending on context | charting |
| q | Every (Quaque) | Latin prefix meaning every; used with time intervals in medication orders | medications |
| q2h | Every 2 Hours | Medication or assessment frequency of once every two hours | medications |
| q4h | Every 4 Hours | Medication or assessment frequency of once every four hours | medications |
| q6h | Every 6 Hours | Medication or assessment frequency of once every six hours | medications |
| q8h | Every 8 Hours | Medication or assessment frequency of once every eight hours | medications |
| QD | Every Day (Quaque Die) Do not use (Joint Commission) | On The Joint Commission's Do Not Use list because QD can be misread as QID (four times a day). Write "daily" instead | medications |
| QHS | Every Night at Bedtime | Medication timing for nightly administration before sleep | medications |
| QID | Four Times a Day (Quater in Die) | Medication frequency indicating four doses per day | medications |
| QOD | Every Other Day Do not use (Joint Commission) | On The Joint Commission's Do Not Use list because QOD can be misread as QD (daily) or QID (four times a day). Write "every other day" instead | medications |
| RA | Rheumatoid Arthritis / Room Air | Autoimmune joint disease, or breathing ambient air without supplemental oxygen | diagnoses |
| RBC | Red Blood Cell | Blood cell carrying oxygen from the lungs to the body's tissues | lab-values |
| RCA | Right Coronary Artery | Coronary artery supplying blood to the right side of the heart | general |
| RLL | Right Lower Lobe | Lower section of the right lung | assessments |
| RLQ | Right Lower Quadrant | Lower right section of the abdomen; appendicitis pain often presents here | assessments |
| RML | Right Middle Lobe | Middle section of the right lung | assessments |
| RN | Registered Nurse | Licensed nurse who has passed the NCLEX-RN examination | general |
| R/O | Rule Out | Diagnostic process to eliminate or confirm a suspected condition | charting |
| ROM | Range of Motion | Degree of movement at a joint during physical assessment | assessments |
| ROSC | Return of Spontaneous Circulation | Resumption of sustained heart function after cardiac arrest | procedures |
| RR | Respiratory Rate | Number of breaths per minute; normal adult range is 12-20 | vitals |
| RRT | Rapid Response Team | Team activated for patients showing signs of clinical deterioration | general |
| RSI | Rapid Sequence Intubation | Technique for quick sedation and paralysis for emergency intubation | procedures |
| RT | Respiratory Therapy | Healthcare specialty focused on cardiopulmonary care | general |
| RUL | Right Upper Lobe | Upper section of the right lung | assessments |
| RUQ | Right Upper Quadrant | Upper right section of the abdomen; gallbladder and liver are located here | assessments |
| Rx | Prescription / Treatment | Written order for medication or therapeutic treatment | charting |
| s/s | Signs and Symptoms | Observable indicators and patient-reported complaints of a condition | charting |
| SA | Sinoatrial | Relating to the SA node, the heart's natural pacemaker | vitals |
| SAH | Subarachnoid Hemorrhage | Bleeding in the space between the brain and surrounding tissue | diagnoses |
| SBAR | Situation, Background, Assessment, Recommendation | Structured communication tool for reporting patient information | charting |
| SBP | Systolic Blood Pressure | Pressure in arteries when the heart beats; top number of a BP reading | vitals |
| SCD | Sequential Compression Device | Inflatable leg sleeves preventing DVT in immobile patients | procedures |
| SDH | Subdural Hematoma | Collection of blood between the brain and its outermost covering | diagnoses |
| SIADH | Syndrome of Inappropriate Antidiuretic Hormone | Condition causing excessive water retention and dilutional hyponatremia | diagnoses |
| SIRS | Systemic Inflammatory Response Syndrome | Inflammatory state affecting the whole body, often a response to infection | diagnoses |
| SL | Sublingual | Medication route indicating placement under the tongue for absorption | medications |
| SLE | Systemic Lupus Erythematosus | Autoimmune disease where the immune system attacks healthy tissue | diagnoses |
| SNF | Skilled Nursing Facility | Long-term care facility providing 24-hour nursing care | general |
| SOAP | Subjective, Objective, Assessment, Plan | Standard documentation format for clinical notes | charting |
| SOB | Shortness of Breath | Difficulty breathing or feeling unable to get enough air | assessments |
| SpO2 | Peripheral Oxygen Saturation | Oxygen saturation measured by pulse oximetry; normal 95-100% | vitals |
| SQ | Subcutaneous Error-prone (ISMP) | Injection route into the fatty tissue beneath the skin. SQ is on the ISMP error-prone list because it has been misread as "5 every"; ISMP recommends SUBQ (all uppercase) or "subcutaneous" | medications |
| SSRI | Selective Serotonin Reuptake Inhibitor | Class of antidepressant medications blocking serotonin reabsorption | medications |
| SSS | Sick Sinus Syndrome | Group of heart rhythm disorders caused by SA node dysfunction | diagnoses |
| STAT | Immediately (Statim) | Highest priority designation indicating immediate action required | general |
| STD | Sexually Transmitted Disease | Infection spread through sexual contact | diagnoses |
| STI | Sexually Transmitted Infection | Preferred term for infections transmitted through sexual activity | diagnoses |
| STEMI | ST-Elevation Myocardial Infarction | Type of heart attack with complete coronary artery blockage shown on EKG | diagnoses |
| SubQ | Subcutaneous | Alternate abbreviation for the subcutaneous route. ISMP recommends writing SUBQ in uppercase with no space; "sub q" is on its error-prone list because the q has been read as "every" | medications |
| SVT | Supraventricular Tachycardia | Abnormally fast heart rate originating above the ventricles | diagnoses |
| Sx | Symptoms | Patient-reported subjective complaints of illness or distress | charting |
| T | Temperature | Core or peripheral body temperature, normally 97.8-99.1 degrees F | vitals |
| TB | Tuberculosis | Bacterial infection primarily affecting the lungs caused by Mycobacterium tuberculosis | diagnoses |
| TBI | Traumatic Brain Injury | Brain damage caused by an external mechanical force | diagnoses |
| TCDB | Turn, Cough, Deep Breathe | Post-operative pulmonary hygiene instructions to prevent lung complications | procedures |
| TEE | Transesophageal Echocardiogram | Ultrasound of the heart using a probe passed through the esophagus | diagnostics |
| Temp | Temperature | Body temperature measurement, a core vital sign | vitals |
| TENS | Transcutaneous Electrical Nerve Stimulation | Pain management device sending electrical impulses through the skin | procedures |
| TFTs | Thyroid Function Tests | Panel of blood tests measuring TSH, T3, and T4 levels | lab-values |
| TIA | Transient Ischemic Attack | Temporary blockage of blood flow to the brain; warning sign of future stroke | diagnoses |
| TIBC | Total Iron-Binding Capacity | Blood test measuring the blood's capacity to bind iron with transferrin | lab-values |
| TID | Three Times a Day (Ter in Die) | Medication frequency indicating three doses per day | medications |
| TKO | To Keep Open | Minimal IV flow rate to prevent the line from clotting off | medications |
| TKR | Total Knee Replacement | Surgery replacing the knee joint with an artificial implant | procedures |
| TLC | Total Lung Capacity / Tender Loving Care | Maximum volume of air the lungs can hold, or compassionate nursing care | diagnostics |
| TNF | Tumor Necrosis Factor | Inflammatory cytokine involved in systemic inflammation and immune response | lab-values |
| TPA | Tissue Plasminogen Activator Error-prone (ISMP) | Clot-dissolving medication (alteplase) used to treat acute ischemic stroke and PE. On the ISMP error-prone list because TPA has been confused with TNK (tenecteplase) and TXA (tranexamic acid). Write "alteplase" in full | medications |
| TPN | Total Parenteral Nutrition | IV nutrition providing all essential nutrients when oral feeding is not possible | medications |
| TPR | Temperature, Pulse, Respiration | Three basic vital signs typically assessed together | vitals |
| Trach | Tracheostomy | Surgical opening in the neck into the trachea providing an airway | procedures |
| Trig | Triglycerides | Type of fat in the blood; elevated levels increase cardiovascular risk | lab-values |
| TSH | Thyroid-Stimulating Hormone | Pituitary hormone regulating thyroid function; primary test for thyroid disorders | lab-values |
| TTE | Transthoracic Echocardiogram | Non-invasive ultrasound of the heart performed through the chest wall | diagnostics |
| Tx | Treatment / Transplant | Medical intervention provided to a patient or organ replacement surgery | charting |
| T3 | Triiodothyronine | Active thyroid hormone affecting metabolism and body temperature | lab-values |
| T4 | Thyroxine | Thyroid hormone converted to T3; measured in thyroid function tests | lab-values |
| UA | Urinalysis | Laboratory examination of urine for abnormalities | diagnostics |
| UAP | Unlicensed Assistive Personnel | Healthcare worker performing delegated nursing tasks under RN supervision | general |
| UE | Upper Extremity | The arm from shoulder to fingertips | assessments |
| UGI | Upper Gastrointestinal | Imaging series of the esophagus, stomach, and duodenum using barium | diagnostics |
| UO | Urine Output | Volume of urine produced; adequate output is 0.5 mL/kg/hour in adults | assessments |
| URI | Upper Respiratory Infection | Infection of the nose, throat, or sinuses such as the common cold | diagnoses |
| US | Ultrasound | Imaging technique using sound waves to visualize internal structures | diagnostics |
| UTI | Urinary Tract Infection | Bacterial infection of the bladder, urethra, or kidneys | diagnoses |
| VAD | Ventricular Assist Device | Mechanical pump supporting heart function in patients with heart failure | procedures |
| VAP | Ventilator-Associated Pneumonia | Lung infection developing in patients on mechanical ventilation for 48+ hours | diagnoses |
| VBAC | Vaginal Birth After Cesarean | Vaginal delivery in a woman who previously had a cesarean section | procedures |
| VF | Ventricular Fibrillation | Life-threatening heart rhythm with chaotic electrical activity in ventricles | diagnoses |
| VRSA | Vancomycin-Resistant Staphylococcus Aureus | Staph bacteria resistant to vancomycin antibiotic treatment | diagnoses |
| VRE | Vancomycin-Resistant Enterococcus | Intestinal bacteria resistant to vancomycin; requires contact precautions | diagnoses |
| VS | Vital Signs | Core measurements including HR, BP, RR, Temp, and SpO2 | vitals |
| VSD | Ventricular Septal Defect | Hole in the wall between the heart's lower chambers; congenital heart defect | diagnoses |
| VT | Ventricular Tachycardia | Fast, abnormal heart rate originating in the ventricles | diagnoses |
| VTE | Venous Thromboembolism | Blood clot in a vein, encompassing DVT and PE | diagnoses |
| w/u | Workup | Series of diagnostic tests ordered to evaluate a condition | charting |
| WBC | White Blood Cell | Immune system cell that fights infection; elevated count may indicate infection | lab-values |
| WNL | Within Normal Limits | Assessment finding indicating results are in the expected range | charting |
| WOB | Work of Breathing | Effort required for ventilation; assessed for signs of respiratory distress | assessments |
| WT | Weight | Patient body weight used for medication dosing and fluid management | assessments |
| XR | X-Ray | Imaging technique using radiation to produce images of internal structures | diagnostics |
| ABX | Antibiotics | Medications used to treat bacterial infections | medications |
| ADN | Associate Degree in Nursing | Two-year nursing degree qualifying graduates to take the NCLEX-RN exam | general |
| ADR | Adverse Drug Reaction | Unintended and harmful response to a medication at normal doses | medications |
| ADON | Assistant Director of Nursing | Administrative nursing role supporting the Director of Nursing | general |
| AEB | As Evidenced By | Phrase linking a nursing diagnosis to supporting data in care plans | charting |
| AFB | Acid-Fast Bacillus | Staining test used to identify tuberculosis and other mycobacterial infections | diagnostics |
| AHF | Acute Heart Failure | Sudden onset of heart failure symptoms requiring urgent treatment | diagnoses |
| AICD | Automatic Implantable Cardioverter-Defibrillator | Implanted device that monitors and corrects life-threatening heart rhythms | procedures |
| ANS | Autonomic Nervous System | Part of the nervous system controlling involuntary functions like heart rate and digestion | general |
| AROM | Active Range of Motion / Artificial Rupture of Membranes | Joint movement performed by the patient, or procedure to break the amniotic sac | assessments |
| ATC | Around the Clock | Medication schedule with doses given at regular intervals throughout 24 hours | medications |
| AV block | Atrioventricular Block | Heart condition where electrical signals between atria and ventricles are delayed or blocked | diagnoses |
| AVPU | Alert, Verbal, Pain, Unresponsive | Quick assessment scale for level of consciousness | assessments |
| BAL | Bronchoalveolar Lavage | Procedure collecting fluid from the lungs for diagnostic analysis | procedures |
| BBB | Bundle Branch Block | Delay or blockage in the heart's electrical conduction system | diagnoses |
| BOW | Bag of Waters | Amniotic sac surrounding the fetus during pregnancy | general |
| BR | Bed Rest | Activity restriction requiring the patient to remain in bed | general |
| BSC | Bedside Commode | Portable toilet placed next to the patient's bed | general |
| BVM | Bag-Valve Mask | Manual resuscitation device used to provide positive pressure ventilation | procedures |
| CA | Cancer / Carcinoma | Malignant disease characterized by uncontrolled cell growth | diagnoses |
| CAT | Computed Axial Tomography | Older term for CT scan; cross-sectional imaging of the body | diagnostics |
| CAUTI | Catheter-Associated Urinary Tract Infection | UTI occurring in a patient with an indwelling urinary catheter | diagnoses |
| CDI | Clostridioides difficile Infection | Bacterial infection causing severe diarrhea often after antibiotic use | diagnoses |
| CHD | Coronary Heart Disease / Congenital Heart Disease | Narrowing of coronary arteries, or heart defects present at birth | diagnoses |
| CLABSI | Central Line-Associated Bloodstream Infection | Bloodstream infection attributed to a central venous catheter | diagnoses |
| CNA | Certified Nursing Assistant | Entry-level nursing professional providing basic patient care under RN supervision | general |
| COX | Cyclooxygenase | Enzyme targeted by NSAIDs to reduce inflammation and pain | medications |
| CPP | Cerebral Perfusion Pressure | Pressure driving blood flow to the brain; calculated as MAP minus ICP | vitals |
| CRNA | Certified Registered Nurse Anesthetist | Advanced practice nurse specializing in anesthesia administration | general |
| CVD | Cardiovascular Disease | Group of disorders affecting the heart and blood vessels | diagnoses |
| DAT | Diet as Tolerated | Order allowing a patient to eat whatever foods they can handle | general |
| DBS | Dried Blood Spot | Blood sample collected on filter paper for newborn screening tests | diagnostics |
| DDAVP | Desmopressin | Synthetic ADH used to treat diabetes insipidus and bleeding disorders | medications |
| DL | Deciliter | Unit of measurement equal to one-tenth of a liter | general |
| DNAR | Do Not Attempt Resuscitation | Updated terminology for DNR used in some healthcare systems | general |
| DON | Director of Nursing | Senior nursing administrator overseeing nursing operations | general |
| DPP | Dorsalis Pedis Pulse | Pulse felt on the top of the foot used to assess peripheral circulation | assessments |
| DRG | Diagnosis-Related Group | Classification system grouping hospital cases for Medicare payment purposes | general |
| DSM | Diagnostic and Statistical Manual | Reference manual for psychiatric diagnoses published by the APA | general |
| DTs | Delirium Tremens | Severe alcohol withdrawal syndrome with confusion, hallucinations, and seizures | diagnoses |
| EBP | Evidence-Based Practice | Clinical decision-making approach integrating research, expertise, and patient preferences | general |
| ECF | Extended Care Facility / Extracellular Fluid | Long-term care institution, or fluid outside the body's cells | general |
| EGD | Esophagogastroduodenoscopy | Endoscopic procedure examining the esophagus, stomach, and duodenum | procedures |
| EENT | Eyes, Ears, Nose, Throat | Physical examination of the sensory organs of the head | assessments |
| EHR | Electronic Health Record | Digital system for storing and managing patient medical records | charting |
| ELISA | Enzyme-Linked Immunosorbent Assay | Laboratory test detecting antibodies or antigens in a blood sample | diagnostics |
| EMR | Electronic Medical Record | Digital version of a patient's paper chart within one practice | charting |
| EOM | Extraocular Movements | Eye movements tested during neurological and cranial nerve examination | assessments |
| EPAP | Expiratory Positive Airway Pressure | Pressure applied during exhalation in BiPAP ventilation | procedures |
| EDD | Estimated Date of Delivery | Predicted date of birth, 280 days (40 weeks) after the first day of the last menstrual period or set by early ultrasound | general |
| ETA | Estimated Time of Arrival | Expected arrival time of a patient or transport | general |
| FAS | Fetal Alcohol Syndrome | Birth defects from prenatal alcohol exposure including growth and cognitive problems | diagnoses |
| FAST | Focused Assessment with Sonography for Trauma | Rapid ultrasound exam detecting free fluid in trauma patients | assessments |
| FFP | Fresh Frozen Plasma | Blood product containing clotting factors used to correct coagulopathy | medications |
| FHT | Fetal Heart Tones | Sounds of the fetal heartbeat heard during prenatal assessment | assessments |
| FOB | Fecal Occult Blood | Test detecting hidden blood in stool that may indicate GI bleeding or cancer | diagnostics |
| FTT | Failure to Thrive | Inadequate growth or weight gain in infants and children | diagnoses |
| FWB | Full Weight Bearing | Patient can place full body weight on an extremity without restriction | general |
| G | Gauge | Measurement of needle or catheter diameter; smaller number means larger bore | procedures |
| GABA | Gamma-Aminobutyric Acid | Inhibitory neurotransmitter; target of benzodiazepines and other sedatives | medications |
| GBS | Group B Streptococcus / Guillain-Barre Syndrome | Common bacteria screened in pregnancy, or autoimmune nerve disorder | diagnoses |
| GSW | Gunshot Wound | Traumatic injury caused by a firearm projectile | diagnoses |
| H&H | Hemoglobin and Hematocrit | Two blood test values commonly assessed together for anemia screening | lab-values |
| H&P | History and Physical | Comprehensive documentation of patient history and physical examination | charting |
| HAI | Healthcare-Associated Infection | Infection acquired during the course of receiving healthcare treatment | diagnoses |
| HCT | Hematocrit | Percentage of blood volume occupied by red blood cells | lab-values |
| HCTZ | Hydrochlorothiazide Error-prone (ISMP) | Thiazide diuretic commonly used to treat hypertension. On the ISMP error-prone list because HCTZ has been misread as hydrocortisone (HCTZ 50 mg seen as HCT 250 mg). Write "hydrochlorothiazide" in full | medications |
| HHS | Hyperosmolar Hyperglycemic State | Serious diabetic complication with very high blood sugar and dehydration without ketosis | diagnoses |
| HOH | Hard of Hearing | Patient has reduced hearing ability requiring accommodation | assessments |
| HPI | History of Present Illness | Detailed description of the patient's current health problem | charting |
| HSV | Herpes Simplex Virus | Viral infection causing cold sores (HSV-1) or genital herpes (HSV-2) | diagnoses |
| Ht | Height | Patient stature measurement used in BMI and BSA calculations | assessments |
| IADL | Instrumental Activities of Daily Living | Complex activities like cooking, shopping, and managing finances | assessments |
| ICH | Intracerebral Hemorrhage | Bleeding within the brain tissue; a type of hemorrhagic stroke | diagnoses |
| IPAP | Inspiratory Positive Airway Pressure | Pressure applied during inhalation in BiPAP ventilation | procedures |
| ISS | Injury Severity Score | Scoring system for assessing overall severity of multiple injuries in trauma | assessments |
| ITP | Immune Thrombocytopenia (formerly Idiopathic Thrombocytopenic Purpura) | Autoimmune disorder causing low platelet count and easy bruising; an international working group adopted the immune thrombocytopenia name in 2009 | diagnoses |
| LAB | Laboratory | Department where blood and other specimens are analyzed | diagnostics |
| LE | Lower Extremity | The leg from hip to toes | assessments |
| LN | Lymph Node | Small immune system organ that filters lymph fluid | assessments |
| LOA | Left Occiput Anterior | Vertex fetal position with the occiput toward the front of the mother's left side, so the fetus faces the mother's right back | general |
| LOS | Length of Stay | Duration of a patient's hospital admission | charting |
| LPN | Licensed Practical Nurse | Nurse licensed to provide basic care under the supervision of an RN or physician | general |
| LVN | Licensed Vocational Nurse | Term used in Texas and California for LPN | general |
| MAOI | Monoamine Oxidase Inhibitor | Class of antidepressant with significant dietary and drug interactions | medications |
| MCA | Middle Cerebral Artery | Major brain artery; most common site for ischemic stroke | general |
| MCH | Mean Corpuscular Hemoglobin | Average amount of hemoglobin per red blood cell | lab-values |
| MCHC | Mean Corpuscular Hemoglobin Concentration | Average concentration of hemoglobin in red blood cells | lab-values |
| MCV | Mean Corpuscular Volume | Average size of red blood cells; helps classify anemias | lab-values |
| MDR | Multi-Drug Resistant | Organisms resistant to multiple classes of antibiotics | diagnoses |
| MedSurg | Medical-Surgical | General nursing unit caring for adult patients with various conditions | general |
| mg/dL | Milligrams per Deciliter | Common unit of measurement for blood glucose and other lab values | lab-values |
| mmHg | Millimeters of Mercury | Unit of measurement for blood pressure | vitals |
| mmol/L | Millimoles per Liter | SI unit used internationally for measuring lab values including glucose | lab-values |
| MOI | Mechanism of Injury | How an injury occurred; important for trauma assessment | charting |
| MSE | Mental Status Exam | Structured assessment of a patient's psychological functioning | assessments |
| MSDS | Material Safety Data Sheet | Former name for the hazardous-substance information sheet, now called a Safety Data Sheet (SDS) under OSHA's 2012 Hazard Communication Standard | general |
| MVR | Mitral Valve Replacement | Surgery to replace the mitral valve of the heart | procedures |
| N/A | Not Applicable | Entry does not apply to the current patient or situation | charting |
| N/V | Nausea and Vomiting | Common symptoms occurring together in many conditions | assessments |
| N/V/D | Nausea, Vomiting, Diarrhea | Cluster of GI symptoms suggesting gastroenteritis or other conditions | assessments |
| NAC | N-Acetylcysteine | Antidote for acetaminophen overdose; also used as a mucolytic | medications |
| NaHCO3 | Sodium Bicarbonate | Alkalizing agent used to treat metabolic acidosis and certain drug overdoses | medications |
| NCLEX | National Council Licensure Examination | Standardized exam for nursing licensure in the United States | general |
| NEC | Necrotizing Enterocolitis | Serious intestinal disease primarily affecting premature newborns | diagnoses |
| NIBP | Non-Invasive Blood Pressure | Blood pressure measurement using an external cuff rather than arterial line | vitals |
| NJ | Nasojejunal | Tube inserted through the nose into the jejunum for feeding | procedures |
| NOS | Not Otherwise Specified | Qualifier indicating a diagnosis does not fit a more specific category | charting |
| NSTEMI | Non-ST-Elevation Myocardial Infarction | Type of heart attack without ST elevation on EKG but with elevated cardiac enzymes | diagnoses |
| OBS | Observation | Hospital status for monitoring patients who may not require full admission | charting |
| OG | Orogastric | Tube inserted through the mouth into the stomach | procedures |
| OSHA | Occupational Safety and Health Administration | Federal agency ensuring workplace safety standards | general |
| OTC | Over the Counter | Medications available without a prescription | medications |
| PAD | Peripheral Arterial Disease | Narrowing of peripheral arteries reducing blood flow to extremities | diagnoses |
| PCC | Prothrombin Complex Concentrate | Blood product used to reverse warfarin and treat bleeding emergencies | medications |
| PCO2 | Partial Pressure of Carbon Dioxide | ABG measurement of carbon dioxide levels in the blood | lab-values |
| PCT | Patient Care Technician | Healthcare worker assisting with basic patient care tasks | general |
| PEJ | Percutaneous Endoscopic Jejunostomy | Feeding tube placed directly into the jejunum through the abdominal wall | procedures |
| PERRL | Pupils Equal, Round, Reactive to Light | Normal pupillary assessment finding during neurological exam | assessments |
| PICU | Pediatric Intensive Care Unit | Hospital unit providing critical care for children | general |
| PIH | Pregnancy-Induced Hypertension | Older term for high blood pressure developing after 20 weeks of pregnancy; ACOG now uses gestational hypertension and preeclampsia | diagnoses |
| PLT | Platelet | Blood cell fragment essential for clotting; counted in CBC | lab-values |
| PMI | Point of Maximum Impulse | Location on the chest where the heartbeat is felt strongest | assessments |
| PNB | Peripheral Nerve Block | Regional anesthesia technique numbing a specific nerve or nerve group | procedures |
| PO2 | Partial Pressure of Oxygen | ABG measurement of oxygen dissolved in the blood | lab-values |
| POCT | Point of Care Testing | Medical testing performed at or near the site of patient care | diagnostics |
| PP | Postpartum | Period after childbirth typically spanning six weeks | general |
| PPH | Postpartum Hemorrhage | Excessive bleeding after birth. ACOG (2017) defines it as cumulative blood loss of 1,000 mL or more, or blood loss with signs of hypovolemia, within 24 hours of birth regardless of route; WHO uses more than 500 mL | diagnoses |
| PROM | Prelabor Rupture of Membranes (formerly Premature Rupture of Membranes) | Rupture of the amniotic sac before labor begins; before 37 weeks it is called preterm PROM (PPROM) | diagnoses |
| PSI | Pounds per Square Inch / Pneumonia Severity Index | Unit of pressure, or scoring tool for community-acquired pneumonia severity | assessments |
| PTX | Pneumothorax | Collapsed lung from air leaking into the space around the lung | diagnoses |
| PVT | Pulseless Ventricular Tachycardia / Paroxysmal Ventricular Tachycardia | In ACLS, ventricular tachycardia without a pulse, a shockable cardiac arrest rhythm; also used for sudden episodes of ventricular tachycardia | diagnoses |
| PWB | Partial Weight Bearing | Patient may place some but limited weight on an affected extremity | general |
| QA | Quality Assurance | Systematic process ensuring healthcare services meet established standards | general |
| QC | Quality Control | Procedures ensuring the accuracy of laboratory test results | general |
| QI | Quality Improvement | Ongoing effort to improve patient care outcomes and processes | general |
| RACE | Rescue, Alarm, Contain, Extinguish | Fire response protocol used in healthcare facilities | general |
| RBBB | Right Bundle Branch Block | Delay in electrical conduction through the right bundle branch of the heart | diagnoses |
| RDS | Respiratory Distress Syndrome | Breathing disorder in premature infants due to insufficient surfactant | diagnoses |
| RLE | Right Lower Extremity | The right leg | assessments |
| ROS | Review of Systems | Systematic questioning about symptoms in each body system during assessment | charting |
| RSV | Respiratory Syncytial Virus | Common respiratory virus especially dangerous for infants and elderly | diagnoses |
| RUE | Right Upper Extremity | The right arm | assessments |
| SaO2 | Arterial Oxygen Saturation | Oxygen saturation measured from an arterial blood sample in ABG testing | lab-values |
| SBT | Spontaneous Breathing Trial | Test assessing a ventilated patient's readiness for extubation | procedures |
| SCr | Serum Creatinine | Blood test measuring kidney function; elevated levels indicate impaired filtration | lab-values |
| SDS | Same Day Surgery | Surgical procedure where the patient is discharged the same day | general |
| SGA | Small for Gestational Age | Newborn whose weight is below the 10th percentile for gestational age | assessments |
| SIMV | Synchronized Intermittent Mandatory Ventilation | Ventilator mode combining mandatory and spontaneous breaths | procedures |
| SJS | Stevens-Johnson Syndrome | Severe, life-threatening skin reaction usually triggered by medication | diagnoses |
| SLP | Speech-Language Pathologist | Specialist treating speech, language, and swallowing disorders | general |
| SNS | Sympathetic Nervous System | Division of the autonomic nervous system activating the fight-or-flight response | general |
| SOC | Start of Care | Date when home health or hospice services begin for a patient | charting |
| SPECT | Single-Photon Emission Computed Tomography | Nuclear imaging test showing how blood flows through organs | diagnostics |
| SSI | Sliding Scale Insulin / Surgical Site Infection Error-prone (ISMP) | Sliding scale insulin, or infection at a surgical wound. In medication orders SSI is on the ISMP error-prone list (misread as strong solution of iodine), so write "sliding scale insulin" in full | medications |
| TAH | Total Abdominal Hysterectomy | Surgical removal of the uterus through an abdominal incision | procedures |
| TAO | Thromboangiitis Obliterans | Inflammatory vascular disease strongly associated with tobacco use | diagnoses |
| TBSA | Total Body Surface Area | Measurement of skin area affected, used in burn assessment and treatment | assessments |
| TCA | Tricyclic Antidepressant | Older class of antidepressant with significant side effects and overdose risk | medications |
| TD | Tardive Dyskinesia | Involuntary movements caused by long-term antipsychotic medication use | diagnoses |
| THR | Total Hip Replacement | Surgery replacing the hip joint with an artificial implant | procedures |
| TLSO | Thoracolumbosacral Orthosis | Rigid brace supporting the spine from thoracic to sacral region | procedures |
| TNM | Tumor, Node, Metastasis | Cancer staging system describing tumor size, lymph node involvement, and spread | diagnoses |
| TOF | Tetralogy of Fallot | Congenital heart defect consisting of four structural abnormalities | diagnoses |
| TORCH | Toxoplasmosis, Other, Rubella, CMV, Herpes | Panel of tests screening for infections that can cause birth defects | diagnostics |
| tPA | Tissue Plasminogen Activator Error-prone (ISMP) | Thrombolytic drug (alteplase) used to dissolve blood clots in stroke and PE. On the ISMP error-prone list because tPA has been confused with TNK (tenecteplase) and TXA (tranexamic acid). Write "alteplase" in full | medications |
| TURP | Transurethral Resection of the Prostate | Surgery removing prostate tissue to relieve urinary obstruction | procedures |
| TWA | Time-Weighted Average | Average occupational exposure concentration over a standard workday | general |
| UDS | Urine Drug Screen | Test detecting the presence of drugs or their metabolites in urine | diagnostics |
| ULN | Upper Limit of Normal | Highest value considered normal for a particular lab test | lab-values |
| UOP | Urine Output | Volume of urine produced over a measured time period | assessments |
| VAC | Vacuum-Assisted Closure | Wound therapy using negative pressure to promote healing | procedures |
| VATS | Video-Assisted Thoracoscopic Surgery | Minimally invasive chest surgery using a small camera and instruments | procedures |
| VO2 | Oxygen Consumption | Rate at which the body uses oxygen during metabolism | vitals |
| VP | Ventriculoperitoneal | Shunt draining excess cerebrospinal fluid from the brain to the abdomen | procedures |
| WBAT | Weight Bearing as Tolerated | Patient may bear as much weight on an extremity as comfort allows | general |
| WPW | Wolff-Parkinson-White Syndrome | Heart condition with an extra electrical pathway causing rapid heart rate | diagnoses |
| XRT | Radiation Therapy (X-Ray Therapy) | Cancer treatment using high-energy radiation to destroy tumor cells | procedures |