Medical Abbreviations: Complete A-Z Reference Guide
Comprehensive list of common medical abbreviations, acronyms, and terminology for healthcare documentation. Includes JCAHO Do Not Use list and specialty-specific abbreviations.
Understanding Medical Abbreviations
Medical abbreviations have been used in healthcare for nearly 200 years, evolving from prescription shorthand to a comprehensive system used across all aspects of clinical documentation. Understanding these abbreviations is essential for effective communication between healthcare providers.
Important Safety Note
Some abbreviations have multiple meanings depending on context (e.g., "CA" could mean cardiac arrest or carcinoma). Always use context clues and when in doubt, write out the full term to prevent dangerous misinterpretations.
Common Medical Abbreviations by Category
A comprehensive reference organized by clinical context for easy lookup.
Vital Signs & Measurements
| Abbreviation | Meaning |
|---|---|
BP | Blood Pressure |
HR | Heart Rate |
RR | Respiratory Rate |
T / Temp | Temperature |
SpO2 | Oxygen Saturation |
BMI | Body Mass Index |
RA | Room Air |
NC | Nasal Cannula |
L/min | Liters per minute |
History & Examination
| Abbreviation | Meaning |
|---|---|
CC | Chief Complaint |
HPI | History of Present Illness |
PMH | Past Medical History |
PSH | Past Surgical History |
FH | Family History |
SH | Social History |
ROS | Review of Systems |
PE | Physical Examination |
HEENT | Head, Eyes, Ears, Nose, Throat |
NAD | No Acute Distress |
WNL | Within Normal Limits |
NKDA | No Known Drug Allergies |
Diagnosis & Assessment
| Abbreviation | Meaning |
|---|---|
Dx | Diagnosis |
DDx | Differential Diagnosis |
Hx | History |
Sx | Symptoms |
S/S | Signs and Symptoms |
R/O | Rule Out |
SOB | Shortness of Breath |
c/o | Complains of |
N/V | Nausea/Vomiting |
A&O | Alert and Oriented |
Treatment & Plan
| Abbreviation | Meaning |
|---|---|
Tx | Treatment |
Rx | Prescription/Treatment |
Mx | Management |
D/C | Discharge or Discontinue |
f/u | Follow-up |
RTC | Return to Clinic |
PT | Physical Therapy |
OT | Occupational Therapy |
NPO | Nothing by Mouth (Nil Per Os) |
PRN | As Needed (Pro Re Nata) |
Medication Frequency
| Abbreviation | Meaning |
|---|---|
QD / daily | Once daily |
BID | Twice daily |
TID | Three times daily |
QID | Four times daily |
QHS | At bedtime (Quaque Hora Somni) |
AC | Before meals (Ante Cibum) |
PC | After meals (Post Cibum) |
Q4H | Every 4 hours |
Q6H | Every 6 hours |
Q8H | Every 8 hours |
Routes of Administration
| Abbreviation | Meaning |
|---|---|
PO | By mouth (Per Os) |
IV | Intravenous |
IM | Intramuscular |
SQ / SC | Subcutaneous |
SL | Sublingual |
PR | Per rectum |
TOP | Topical |
INH | Inhalation |
GTT | Drops (guttae) |
OD/OS/OU | Right eye/Left eye/Both eyes |
Common Conditions
| Abbreviation | Meaning |
|---|---|
HTN | Hypertension |
DM / DM2 | Diabetes Mellitus (Type 2) |
CAD | Coronary Artery Disease |
CHF | Congestive Heart Failure |
COPD | Chronic Obstructive Pulmonary Disease |
CKD | Chronic Kidney Disease |
MI | Myocardial Infarction |
CVA | Cerebrovascular Accident (Stroke) |
DVT | Deep Vein Thrombosis |
PE | Pulmonary Embolism |
UTI | Urinary Tract Infection |
URI | Upper Respiratory Infection |
Laboratory & Diagnostics
| Abbreviation | Meaning |
|---|---|
CBC | Complete Blood Count |
BMP | Basic Metabolic Panel |
CMP | Comprehensive Metabolic Panel |
LFTs | Liver Function Tests |
UA | Urinalysis |
CXR | Chest X-Ray |
CT | Computed Tomography |
MRI | Magnetic Resonance Imaging |
EKG/ECG | Electrocardiogram |
NSR | Normal Sinus Rhythm |
ABG | Arterial Blood Gas |
BNP | Brain Natriuretic Peptide |
JCAHO "Do Not Use" Abbreviations
The Joint Commission requires healthcare organizations to avoid these dangerous abbreviations that have led to medication errors and patient harm.
DO NOT USE
U or uIntended Meaning
Unit
Problem
Mistaken for "0" (zero), "4" (four), or "cc"
USE INSTEAD
Write "unit"
DO NOT USE
IUIntended Meaning
International Unit
Problem
Mistaken for "IV" (intravenous) or "10" (ten)
USE INSTEAD
Write "international unit"
DO NOT USE
Q.D., QD, q.d., qdIntended Meaning
Daily
Problem
Mistaken for Q.I.D. (four times daily)
USE INSTEAD
Write "daily"
DO NOT USE
Q.O.D., QOD, q.o.d., qodIntended Meaning
Every other day
Problem
Mistaken for Q.D. (daily) or Q.I.D. (four times daily)
USE INSTEAD
Write "every other day"
DO NOT USE
Trailing zero (1.0 mg)Intended Meaning
1 mg
Problem
Decimal point may be missed, resulting in 10-fold error
USE INSTEAD
Write "1 mg"
DO NOT USE
Lack of leading zero (.5 mg)Intended Meaning
0.5 mg
Problem
Decimal point may be missed, resulting in 10-fold error
USE INSTEAD
Write "0.5 mg"
DO NOT USE
MS, MSO4, MgSO4Intended Meaning
Morphine sulfate or Magnesium sulfate
Problem
Can be confused for one another
USE INSTEAD
Write "morphine sulfate" or "magnesium sulfate"
DO NOT USE
ฮผgIntended Meaning
Microgram
Problem
Mistaken for "mg" (milligram)
USE INSTEAD
Write "mcg"
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Frequently Asked Questions
What are the most common medical abbreviations?
The most commonly used medical abbreviations include: BP (blood pressure), HR (heart rate), RR (respiratory rate), Temp (temperature), Hx (history), Dx (diagnosis), Tx (treatment), Rx (prescription), PRN (as needed), and BID/TID/QID (twice/three times/four times daily). These are used daily in clinical documentation across all healthcare settings.
What abbreviations should never be used in medical documentation?
The Joint Commission maintains a "Do Not Use" list of dangerous abbreviations. These include: U or u (write "unit"), IU (write "international unit"), Q.D./QD (write "daily"), Q.O.D./QOD (write "every other day"), trailing zeros like 1.0 mg (write "1 mg"), lack of leading zeros like .5 mg (write "0.5 mg"), and MS/MSO4/MgSO4 (write out "morphine sulfate" or "magnesium sulfate").
Why are medical abbreviations important?
Medical abbreviations serve several important purposes: they save time during documentation, enable efficient communication between healthcare providers, standardize medical terminology, and make chart notes more concise and readable. However, they must be used correctly and consistently to avoid dangerous misinterpretations that could lead to medication errors or patient harm.
How do I know which medical abbreviations are approved?
Each healthcare organization should maintain a list of approved abbreviations. The Joint Commission requires hospitals to have standardized abbreviation lists and prohibits certain dangerous abbreviations. When in doubt, write out the full term. Electronic health records often have built-in abbreviation expansion to help ensure consistency.
Can AI medical scribes handle abbreviations correctly?
Yes, AI medical scribes like PatientNotes are trained to use appropriate medical abbreviations in documentation. They can expand or abbreviate terms based on context and organizational preferences, and they avoid dangerous abbreviations on the Do Not Use list. The AI learns from clinical context to use abbreviations appropriately.
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