Medical Transcription Abbreviation List:
| A&O | alert and oriented |
| A&P | auscultation and percussion |
| A&W | alive and well |
| A&P | Assessment and Plan |
| AA | Alcoholics Anonymous |
| AAA | abdominal aortic aneurysm |
| AAROM | active-assistive range of motion |
| AB | abortion / abdominal / antibody |
| ABCD | asymmetry, border, color, diameter (occurs in dermatology files – describes melanoma) |
| ABD | abdomen |
| ABE | acute bacterial endocarditis |
| ABF | aortobifemoral |
| ABG | arterial blood gas (most common expansion) / air-bone gap |
| ABI | ankle-brachial index |
| AC | acromioclavicular |
| a.c. | before meals |
| accel(s) | acceleration(s) |
| ACE | angiotensin-converting enzyme / acute cerebral encephalopathy |
| ACF | acute care facility |
| ACL | anterior cruciate ligament |
| ACLF | assisted care living facility |
| ACLS | advanced cardiac life support |
| ACS | acute coronary syndrome |
| ad lib | as desired |
| ADD | attention deficit disorder |
| ADHD | attention deficit hyperactivity disorder |
| ADL | activities of daily living |
| ADR | adverse drug reaction / Adriamycin / acute dystonic reaction |
| AFI | amniotic fluid index |
| Afib (slang) | atrial fibrillation |
| AFO | ankle-foot orthosis |
| AFP | alpha fetoprotein |
| AGA | appropriate for gestational age |
| AICD | automatic implantable cardioverter-defibrillator |
| AIDS | acquired immunodeficiency syndrome |
| AKA | above-knee amputation |
| AI | aortic insufficiency |
| ALL | acute lymphocytic leukemia / acute lymphoblastic leukemia |
| AMA | against medical advice |
| AML |
acute myelogenous leukemia
|
| AS | aortic stenosis |
| ATN | acute tubular necrosis |
| AVR | aortic valve replacement |
| BBB | bundle branch block |
| BiPAP | bilevel positive airway pressure |
| BKA | below-knee amputation |
| BMI | body mass index |
| BOOP | bronchiolitis obliterans-organizing pneumonia |
| BP | blood pressure |
| BPH | benign prostatic hypertrophy / benign prostatic hyperplasia |
| BSO | bilateral salpingo-oophorectomy |
| BSS | balanced salt solution |
| C. diff | Clostridium difficile |
| CABG (sounds “cabbage”) | coronary artery bypass graft |
| CAD | coronary artery disease |
| cath | catheter / catheterization |
| CBD | common bile duct |
| CBI | continuous bladder irrigation |
| CCE | clubbing, cyanosis, edema |
| CCU | coronary care unit |
| CHF | congestive heart failure |
| CIC | clean intermittent catheterization |
| CLL | chronic lymphocytic leukemia |
| CML | chronic myelogenous leukemia |
| CMT | cervical motion tenderness / Charcot-Marie-Tooth |
| CMV | cytomegalovirus |
| CNS | central nervous system |
| C&S | culture and sensitivity |
| COPD | chronic obstructive pulmonary disease |
| CPAP | continuous positive airway pressure |
| CPD | cephalopelvic disproportion |
| CPM | continuous passive motion (device) – ortho, rehab files |
| CPR | cardiopulmonary resuscitation |
| CPS | Child Protective Services |
| C section | cesarean section |
| CSF | cerebrospinal fluid |
| C-spine | cervical spine |
| CTA | clear to auscultation |
| CTAP | clear to auscultation and percussion |
| CVA | cerebrovascular accident / costovertebral angle |
| D&C | dilatation and curettage / dilation and curettage |
| DC | discharge OR discontinue |
| DCIS | ductal carcinoma in situ |
| DDD | degenerative disk disease |
| DIC | disseminated intravascular coagulopathy |
| DIP | distal interphalangeal (joint) |
| DJD | degenerative joint disease |
| DKA | diabetic ketoacidosis |
| DM | diabetes mellitus |
| DME | durable medical equipment / director of medical education / degenerative myoclonus epilepsy |
| DNI | do not intubate |
| DNR | do not resuscitate / DO NOT RESUSCITATE |
| DRE | digital rectal exam |
| DTR | deep tendon reflex |
| DT / DTs | delirium tremens |
| DVT | deep vein thrombosis / deep venous thrombosis |
| EBL | estimated blood loss |
| EBRT | external beam radiation therapy |
| EBV | Epstein-Barr virus |
| ECA | external carotid artery |
| ECT | electroconvulsive therapy |
| EDC | estimated date of confinement / estimated date of conception |
| EF | ejection fraction |
| EGA | estimated gestational age |
| EGBUS | external genitalia, Bartholin, urethral and Skene (glands) |
| EGD | esophagogastroduodenoscopy |
| EGJ | esophagogastric junction |
| EHL | extensor hallucis longus |
| EKG | electrocardiogram |
| EMG | electromyogram |
| EMS | emergency medical services |
| EMT | emergency medical technician |
| ENT | ears, nose, throat |
| EOM | extraocular movement / extraocular muscle |
| EOMI | extraocular movements intact / extraocular muscles intact |
| EOMS | extraocular movements / extraocular muscles |
| EPS | electrophysiologic study |
| ER | emergency room |
| ERCP | endoscopic retrograde cholangiopancreatography |
| ESR | erythrocyte sedimentation rate |
| ESRD | end-stage renal disease |
| ESWL | extracorporeal shock wave lithotripsy |
| ET | endotracheal tube |
| ETOH | ethanol |
| FBS | fasting blood sugar |
| FEV1 | forced expiratory volume in one second |
| FFP | fresh frozen plasma |
| FNA | fine needle aspiration |
| GAD | generalized anxiety disorder |
| GBS | group B strep / – group B streptococcus |
| GC | gonorrhea |
| GCS | Glasgow coma scale |
| GERD | gastroesophageal reflux disease |
| GTT | glucose tolerance test |
| G-tube | gastrostomy tube |
| GU | genitourinary |
| GYN | gynecology |
| H&H | hemoglobin and hematocrit |
| H&P | history and physical |
| HBO | hyperbaric oxygen |
| HCG | human chorionic gonadotropin |
| HCT | hematocrit |
| HCTZ | hydrochlorothiazide |
| HEENT | head, eyes, ears, nose, and throat |
| HEME/ONC | hematology/oncology |
| HGB / Hgb | hemoglobin |
| HIV | human immunodeficiency virus |
| HNP | herniated nucleus pulposus |
| HPI | history of present illness |
| HPV | human papilloma virus |
| HR | heart rate / hallux rigidus / Harrington rod |
| HRT | hormone replacement therapy |
| HSM | hepatosplenomegaly |
| HSV | herpes simplex virus |
| HTN | hypertension |
| I&D | incision and drainage / irrigation and debridement |
| I&O | in and out / input and output / intake and output |
| IBD | inflammatory bowel disease / irritable bowel disease |
| IBS | irritable bowel syndrome |
| ICD | implantable cardioverter-defibrillator |
| ICP | intracranial pressure |
| ICU | intensive care unit |
| ID | infectious disease |
| IDA | iron-deficiency anemia |
| IDC | idiopathic dilated cardiomyopathy / infiltrating ductal carcinoma |
| IDD | insulin-dependent diabetes |
| IDDM | insulin-dependent diabetes mellitus |
| ILD | interstitial lung disease |
| IM | intramedullary / intramuscular |
| IMF | intermaxillary fixation / idiopathic myelofibrosis / inframammary fold |
| IOL | intraocular lens |
| IOP | intraocular pressure |
| IP | interphalangeal |
| IT | iliotibial |
| ITP | idiopathic thrombocytopenic purpura |
| IUD | intrauterine device |
| IUP | intrauterine pregnancy |
| IV | intravenous |
| IVC | inferior vena cava |
| IVP | intravenous pyelogram |
| IVUS | intravascular ultrasound |
| JP | Jackson-Pratt / as in JP drain or Jackson-Pratt drain |
| JVD | jugular venous distention |
| JVP | jugular venous pressure |
| KUB | kidneys, ureters, bladder |
| L&D | labor and delivery |
| LAD | left anterior descending / left axis deviation |
| LBBB | left bundle branch block |
| LFT | liver function test |
| LIMA | left internal mammary artery |
| LLQ | left lower quadrant |
| LMA | laryngeal mask airway |
| LMP | last menstrual period |
| LP | lumbar puncture |
| LR | lactated Ringer |
| LS | lumbrosacral |
| L-spine | lumbar spine |
| LV | left ventricle / left ventricular |
| LVEDP | left ventricular end-diastolic pressure |
| LVH | left ventricular hypertrophy |
| lytes (slang) | electrolytes |
| MAC | monitored anesthesia care |
| MAR | medication administration record |
| MCL | medial collateral ligament |
| MCP | metacarpophalangeal |
| MDI | metered-dose inhaler |
| MI | myocardial infarction |
| MOM | milk of magnesia |
| MR | mitral regurgitation |
| MRSA (sounds “MERSA”) | methicillin-resistant Staphylococcus aureus |
| MS | mitral stenosis / morphine sulfate / multiple sclerosis |
| MSSA | methicillin-susceptible Staphylococcus aureus |
| MTP | metatarsophalangeal (joint) |
| MVR | mitral valve replacement |
| NAD | no apparent (acute) distress |
| NG tube | nasogastric tube |
| NICU | neonatal intensive care unit |
| NIDDM | non-insulin-dependent diabetes mellitus |
| NKDA | no known drug allergies |
| NOS | not otherwise specified |
| n.p.o. | nothing by mouth |
| NSAID | nonsteroidal anti-inflammatory drug |
| NSR | normal sinus rhythm |
| NSVD | normal spontaneous vaginal delivery |
| NYHA | New York Heart Association |
| O&P | ova and parasites (dictated in stool exam results) |
| OA | osteoarthritis / occiput anterior |
| OB | obstetrics |
| OCD | obsessive-compulsive disorder |
| OD | right eye |
| OR | operating room |
| ORIF | open reduction and internal fixation |
| OSA | obstructive sleep apnea |
| OT | occupational therapy |
| OTC | over the counter |
| OU | both eyes |
| PACU | postanesthesia care unit |
| PAF | paroxysmal atrial fibrillation / platelet-activating factor / pollen adherence factor |
| PCA | patient-controlled analgesia |
| PCI | percutaneous coronary intervention |
| PCL | posterior cruciate ligament |
| PCP | primary care physician |
| PDA | posterior descending artery / patent ductus arteriosus |
| PE | physical examination |
| PE | pulmonary embolism (or embolus) |
| PEG | percutaneous endoscopic gastrostomy |
| PERRLA | pupils equal, round, reactive to light and accommodation |
| PFO | patent foramen ovale |
| PFT | pulmonary function test |
| PICC | peripherally inserted central catheter |
| PID | pelvic inflammatory disease |
| PIP | proximal interphalangeal |
| PMD | primary/private medical doctor |
| PMH | past medical history |
| PMI | point of maximal impulse |
| PND | paroxysmal nocturnal dyspnea |
| PPI | proton pump inhibitor |
| PRBCs | packed red blood cells |
| protime | prothrombin time |
| PSA | prostate-specific antigen |
| PT | physical therapy / posterior tibial / prothrombin time |
| PTCA | percutaneous transluminal coronary angioplasty |
| PTSD | post-traumatic stress disorder |
| PUBS | percutaneous umbilical cord blood sampling / perforations, ulcers, and bleeds |
| PVC | premature ventricular contraction |
| PVD | peripheral vascular disease |
| PVR | postvoid residual |
| R/O | rule out |
| RA | rheumatoid arthritis |
| RBBB | right bundle branch block |
| RCA | right coronary artery |
| RDI | respiratory disturbance index |
| RDS | respiratory distress syndrome |
| ROM | range of motion / rupture of membranes |
| ROMI | rule out myocardial infarction |
| ROS | review of systems |
| RR | respiratory rate |
| RRR | regular rate and rhythm |
| RSD | reflex sympathetic dystrophy |
| RSV | respiratory syncytial virus |
| RV | right ventricle |
| RVR | rapid ventricular response |
| S/P | status post |
| SBE | subacute bacterial endocarditis / self-breast examination |
| SCD | sequential compression device |
| SFA | superficial femoral artery |
| SI | sacroiliac (joint) |
| SIDS | sudden infant death syndrome |
| SLE | systemic lupus erythematosus / slit-lamp exam |
| SLR | straight leg raise |
| SNF | skilled nursing facility |
| SPEP | serum protein electrophoresis |
| subcu /subq | subcutaneous or subcutaneously |
| SSEPs | somatosensory evoked potential |
| SSI | sliding scale insulin |
| SSRI | selective serotonin reuptake inhibitor |
| STD | sexually transmitted disease |
| SVC | superior vena cava |
| SVG | saphenous vein graft |
| T&A | tonsillectomy and adenoidectomy |
| TAH | total abdominal hysterectomy |
| TAHBSO | total abdominal hysterectomy and bilateral salpingo-oophorectomy |
| TCC | transitional cell cancer |
| TEE | transesophageal echocardiography |
| TFCC | triangular fibrocartilage complex |
| THA | total hip arthroplasty |
| THR | total hip replacement |
| TIA | transient ischemic attack |
| tib-fib | tibia and fibula |
| TIPS | transjugular intrahepatic portosystemic shunt |
| TKA | total knee arthroplasty |
| TKR | total knee replacement |
| TLIF | transforaminal lumbar interbody fusion |
| TM | tympanic membrane |
| TMJ | temporomandibular joint |
| TPN | total parenteral nutrition |
| TR | tricuspid regurgitation |
| T-spine | thoracic spine |
| TURP | transurethral resection of the prostate |
| UA | urinalysis |
| UPEP | urine protein electrophoresis |
| UPJ | ureteropelvic junction |
| UPPP | uvulopalatopharyngoplasty |
| URI | upper respiratory infection |
| UTI | urinary tract infection |
| UVJ | ureterovesical junction |
| VBAC | vaginal birth after cesarean section |
| VCUG | voiding cystourethrogram |
| VF | ventricular fibrillation |
| VSD | ventriculoseptal defect |
| VT | ventricular tachycardia |
| VTA | vascular targeting agent / ventral tegmental area |
| WDWN | well developed, well nourished |