Medical Terminology Information Sheet:

Medical Chart Organization:

Demographics and insurance
Flow sheets
Physician Orders
Visit notes
Laboratory results
Radiology results
Consultant notes
Other communications

Types of Patient Encounter Notes:
History and Physical
o PE Physical Exam
o Lab Laboratory Studies
o Radiology
x-rays
CT and MRI scans
ultrasounds
o Assessment- Dx (diagnosis) or
DDx (differential diagnosis)
if diagnosis is unclear
o R/O = rule out (if diagnosis is
unclear)
o Plan- Further tests,
consultations, treatment,
recommendations
The SOAP Note
o S = Subjective (what the
patient tells you)
o O = Objective (info from PE,
labs, radiology)
o A = Assessment (Dx and DDx)
o P = Plan (treatment, further
tests, etc.)
Discharge Summary
o Narrative in format
o Summarizes the events of a
hospital stay
o Subjective terminology is used
in the history section (CC, HPI,
etc.)
o Physical examination
terminology




Medical History Terms:
CC Chief Complaint of Patient
HPI History of Present Illness
ROS Review of Systems
PMHx Past Medical History
PSHx Past Surgical History
SHx & FHx Social & Family History
Medications and medication allergies
NKDA = no known drug allergies

Physical Examination Terms:
PE= Physical Exam
(+) = present
(-) = = negative or absent
nl = normal
wnl = within normal limits


Laboratory Terminology:
CBC = complete blood count
Chem 7 (or Chem 8, 14, 20) =
chemistry panels of 7,8,14,or 20
chemistry tests
BMP = basic Metabolic Panel
CMP = complete Metabolic Panel
LFTs = liver function tests
ABG = arterial blood gas
UA = urine analysis
HbA1C= diabetes blood test

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Medical Terms by Body System

HEENT Head, Ears, Eyes, Nose & Throat:
Occipital back of the head
Photophobia intolerant of light
Phonophobia intolerant of sounds
Diplopia double vision
Epistaxis nosebleed
Rhinorrhea runny nose or nasal
discharge
Otorrhea discharge from the ear
Tinnitus ringing noise in the ear
NCAT = normocephalic, atraumatic
PERRL = Pupils Equal Round and
Reactive to Light
Erythema = redness
Exudate (tonsilar) = most commonly
white spots on the tonsils, but can be
any fluid or cellular matter deposited
on any tissue
Purulent = consisting of pus
Injected = blood vessel congestion,
such as red eye

Coronary & Pulmonary:
Cor Coronary (the heart)
Pulm Pulmonary
(respiratory/breathing system)
CTAB no rrw = Lungs are Clear to
auscultation bilaterally, no rales, rhonchi or
wheezes
SOB Shortness of Breath = Dyspnea
Productive cough = phlegm producing
Hemoptysis = coughing up blood
Pleuritic = worse with deep
inspiration/breathing
Retractions = visible skin retractions
with inspiration
Tachypnea = rapid breathing
Breathing sounds:
Rales = crackles = crackling sounds
like velcro being pulled
Rhonchi = wheezes = whistling sounds
Wheezing = high pitched sounds

Abdomen (Abd) or Gastrointestinal (GI):
Anorexia loss or lack of appetite
Post-prandial after eating
Emesis vomiting
NBNB = non-bloody, non-bilious
Hematemesis = bloody emesis
Hematochezia bloody stool
BRBPR Bright Red Blood per
Rectum
Melena tarry black stool
BS = bowel sounds normoactive,
hyperactive, hypoactive, absent
TTP = Abdomen tender to palpation,
often in a single quadrant/area
Guarding = involuntary or voluntary
guarding of painful area.
Rebound pain = worse pain as
examining hand is quickly pulled away

Genitourinary (GU):
GenitoUrinary (GU)
Dysuria = painful urination
Hematuria = blood in the urine

Musculoskeletal & Extremities:
Musculoskeletal (MS)
Extremities (Ext)
Myalgias = Muscle Aches
Arthralgias = Joint Aches
Edema = swelling
Peripheral
Pulmonary

Skin:
Dermatologic (Derm)
Pruritic and non-pruritic = itchy and
non-itchy
Spot
Macule - flat discoloration <10mm in
diameter
Bumps
Papule bump 5mm or less
Nodule well defined bump > 5mm
Plaque raised area
Sacs
Vesicle fluid filled sac <5mm
Bulla fluid filled sac >5mm
Pustule sac filled with pus
Erosion superficial loss of skin
Ulcer deeper loss of skin
Scale dry, flaky areas of skin
Erythema redness

Other:
Neurologic (Neuro)
Paresthesias = tingling sensation
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Common Medical Abbreviations

O2 oxygen
(R) refused
A before (ante)
a fib. atrial fibrillation
a. tach. atrial tachycardia
a.c. or a/c before meals
A.D.L. Activities of Daily Living
A.S.A.P. as soon as possible
A.T. Activity Therapy
Aa of each
AA Alcoholics Anonymous
Ab abortion
Abd abdomen
ABG arterial blood gases
ABP arterial blood pressure
AD Right ear
ad lib As desired
ADA American Diabetic Association
Adm. admitted (admission)
Alc alcohol
Alt alternate
AM morning
AMA against medical advise
amb ambulatory
Amt amount
angio angiogram
Ant anterior
APC Aspirin - Phenacetin - Caffeine
approx. approximately
appt. appointment
aq. water (aqueous)
art. artery
as tol as tollerated
ASA acetylsalicylic acid (aspirin)
AWOL absent without leave
Ax axilla
b.i.d. (BID) twice a day
B/P blood pressure
BE barium enema
blad bladder
BM bowel movement
BUN blood urea nitrogen
Bx behavior
C centigrade
C with
C.S. central service
c/o complains of
Ca cancer
Ca. or Calc. calcium
CABG coronary artery bypass & graft
cal calorie
cap. capsule
card. computerized axial tomography
CAT (CT scan) complete blood count
CC chief complaint
cc cubic centimeter
chol. cholesteral
CL chloride
clav. clavicle
cm centimeter
CNS central nervous system
CO2 carbon dioxide
comf comfortable
conc concentrate
cons consultation
cont continued
contrib contributary
COPD chronic obstructive pulmonary disease
COR 0 acute heart stoppage
cpd compound
CPR cardio-pulmonary resuscitation
cran cranial
CSF cerebral spinal fluid
CVA cerebrovascular accident (stroke)
D & C dilatation & curettage
D.C. Doctor of Chiropractic
D.O. Doctor of Osteopathy
D/C discharge
d/c discontinue
D5W dextrose 5% in water
DD date dictated
decr decreased
defib defibrillation
depr depressed
Diff differential
dil Dilute
dis disease
dist distal
dk drunk
dl deciliters
DOA dead on arrival
DOB date of birth
dr dram
Dr. doctor
DS discharge summary
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DTR's deep tendon reflexes
DT's delerium tremens
Dx diagnosis
ECT electroconvulsive therapy
EEG electroencephalogram
EENT eyes, ears, nose & throat
EKG electrocardiogram
Elev elevate
ENT ears, nose & throat
EOM Extraoccular muscles (movements)
ER emergency room
EST electric shock treatment
EtOH alcohol
etx. external
extr extremeties
f/u Follow up
Fa Father
FBS fasting blood sugar
Fl fluids
ft. foot
FUO fever of unknown origin
Fx fracture
g or gm gm
GB gall bladder
Gen general
genit genitalia
GI gastrointestinal
gluc glucose
Gp group
gr. grain
grav. gravid
GSW gun shot wound
GTT glucose toloerance test
gtt. drop
Gtts. drops
GU genitourinary
Gyn gynecology
H hour
H20 water
H202 hydrogen peroxide
HA headache
Hb husband
Hbg hemoglobin
Hct hematocrit
HCVD hypertensive cardiovascular disease
Hd. head
HEENT head, eyes, ears, nose and throat
hern herniated
HR heart rate
hr hour
HS hour of sleep
ht height
hx history
hyst hysterectomy
I & D Incision and drained
I & O intake and output
I.C. initial contact
id in diem (during the day)
IM intramuscular
inj injured
inpt. inpatient
int internal
IPPB intermittent positive pressure breathing
irreg irregular
irrig irrigate
IV intravenous
IVP intravenous pyelogram
K+ potassium
kg kilogram
KUB kidneys, ureters, and bladder
L Left
L & A light and accomodation
L.P.N. licensed practical nurse
lab laboratory
lac laceration
lap laparotomy or laporoscopy
lat lateral
lb pound
LE
lower extremities or Lupus
Erythematosus
Leuc leucocytes
Lg large or leg
lig ligament
liq liquid
LLQ lower left quadrant
LOA leave of absence
LP Lumbar puncture
LUQ Left upper quadrant
lymphs Lymphocytes
M.D. Physician
m.s.
multiple sclerosis,
morphine sulphate
M.T. movement therapy
max maximum
MCH mean corpuscular hemoglobin
MCHC
mean corpuscular hemoglobin
concentration
MCV mean corpuscular volume
med medical, medid
meds medicines
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mEq/1 milliequivalent per liter
Mg milligram
MI myocardial infarction (heart attack)
Mm millimeter
Mo mother
MR mental retardation
MR# medical record number
NA not available
Na+ no applicable
NBS no bowel sounds
Neg negative
Ng naso-gastric
NKA no known allergies
NMR nuclear magnetic resonance
No. number
Noct night
norm normal
NPN non-protein nitrogen
NPO nothing by mouth
nullip nulleparous (no pregnancies)
o.d. once a day
O.T. occupational therapy
OB obstetrics
OBS organic brain syndrome
OD Right eye
Od over dose
Opd out-patient department
Ops operations
OR operating room
Orth orthopedic
OS Left eye
OU Both eyes
outpt outpatient
Oz ounce
P after
P & A percussion & auscultation
P.E. physical examination
P.I.D. pelvic inflammatory disease
p.o. by mouth
PA postero-anterior
palp palpated
PBI protein bound iodine
Pc after meals
Pdr powder
Ped pediatrics
Pen penicillin
Per by
PERLA
pupils equal reactive to light
and accomodation
pH measure of acidity or alkalinity
Ph.D Doctor of philosophy
phys physical
PM afternoon
PN progress note
pneu pneumonia
pos positive
post posterior
postop postoperative, after surgery
PPD purified protein derivative
preop preoperative, before surgery
prep prepare for
prev previous
prn whenever necessary
pros prostate
prox proximal
Psy. Ser. psychological services
PT physical therapy
pt patient
pvc preventricular contraction
pwd powder
q every
q.__h every ___ hour
q.d. every day
q.h. every hour
q.i.d. Four times a day
q.n. every night
q.o.d. every other day
QA quality assurance
QAC quality Assurance Coordinator
QAP quality Assurance Program
QAR quality Assurance Review
qns quantity not sufficient
R right
R.D. registered dietician
R.N. registered nurse
R.O. reality orientation
R.T.P. recreational Therapeutic Pass
R/O rule out
rad radial
RBC red blood count
rbc Red blood cells
rect rectal
Rh rhesus blood factor
RLQ right lower quadrant
ROS review of systems
RR respiratory rate
RUQ right upper quadrant
Rx prescription, take
s without
S.H. state hospital
S/A sugar and acetone
Sa saline
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Schiz. schizophrenia
Sed rate erythrocycte sedimentation rate
serol serology
SGOT serum glutomie oxalacetic transaminase
SGPT serum glutamic pyruvic transaminase
Sibs siblings
SIDS sudden infant death syndrome
Sig to write , to take
Sl slight
SOAPE
subjective, objective, assessment,
plan, evaluation
SOB shortness of breath
Soc. hx social history
Soc. Ser. social service
Sol solution
Sos when necessary
Sp spine
sp. cd. spinal cord
sp. fl. spinal fluid
sp. gr. specific gravity
Spec. specimen
SQ subcutaneous
Staph staphylococcus
Stat immediately
Strep streptococcus
subcut subcutaneous
Sup superior
Surg surgery
Sx symptoms
Sys system
T & A tonsillectomy and adenoidectomy
T.A. therapeutic assignment
t.i.d. three times a day
T.O. telephone order
Tab tablet
TB tuberculosis
Tbsp. tablespoon
temp. temperature
thor thorax
thromb thrombosis
TLC tender loving care
TM tympanic membrane (eardrum)
TP treatment plan
TPR temperature, pulse, respiration
tsp. teaspoon
Tx treatment
U.O. urinary output
u/o under observation
UA urinanalysis
UGI upper gastrointestinal series (X-ray)
UNK unknown
URI upper respiratory infection
UTI urinary tract infection
v. fib. ventricular fibrillation
v. tach. ventricular tachycardia
V.O. verbal order
Vag vaginal
VC vital capacity
VD veneral disease
VDRL Serological test for syphilis
vit. vitamin
vol volume
VS vital signs
WBC white blood count
wbc white blood cell
wd well developed
wf wife
wk week
wn well nourished
WNL within normal limits
wt. weight
x times
x-ray radiology
y/o year old
yrs years

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