医师写病历是否使用字母缩写？？？（附美国医师常用缩写）
2010-12-01 19:08阅读：
1995年，我原来的医院上三甲，
要求一律写汉字，
原来的英文字母缩写，被禁用。
2000年，我离开的时候，依然禁用。
10年过去了，现在医师写病历、开处方，是否使用常用的字母缩写？？？？
下面，是美国医师常用的英文缩写及含义：
Abbreviation Meaning
a before
ac before meals
abd abdomen
AD Alzheimer’s disease; right
ear
ADL activities of daily
living
ad lib as desired
AKA above the knee
amputation
amb ambulation (walk)
ama, AMA against medical advice,
American Medical Assoc.
AMI acute myocardial
infarction
ANS autonomic nervous
system
appt appointment
ARDS adult respiratory
distress
AROM active range o
f motion
AS left ear; aortic
stenosis
AVR aortic valve
replacement
AV atrioventricular (heart)
ASAP as soon as
possible
ASHD arterisosclerotic heart
disease
BID, bid twice in the
day
BKA below knee amputation
BM bowel movement
BP blood pressure
BPH benign prostatic hypertrophy
(enlarged prostate gland)
BR or br bath room
BSC bed side commode, a
“portable potty chair”
BUN blood urea nitrogen (a
lab test)
Bx or BX biopsy
c with
c/o complaints of
C1 , C2 refers to cervical
vertebra #1, #2, a location
in the spine
Ca, CA cancer
caps capsule with medication in
it
CAD coronary artery disease
(heart disease)
CAT or CT scan computerized
axial tomography ( CAT scan
of the body)
cath catheter (a tube used
to drain out body
fluid)
Medical Abbreviations and Symbols,
page 2
NC DSS Adult and Family
Services Section, November 1,
1998
CABG coronary arterial bypass
graft
CBC complete blood count (
a blood test)
CC chief complaint; cardiac
catheterization
CCU coronary care unit
CHD coronary heart disease
CHF congestive heart
failure
CNS central nervous system
cont. continued
COPD chronic obstructive pulmonary
disease
CO2 carbon
dioxide
CPR cardiopulmonary resuscitation
CXR chest xray
CRF chronic renal failure (kidney
failure)
CVA cerebral vascular
accident
CVD cardiovascular disease
CVS cardiovascular system
cysto cystoscopy
/d per day
DC or D/C discharge
dc discontinue
decub decubitus ulcer (pressure
sore, bedsore)
DJD degenerative joint disease
(osteoarthritis)
DM diabetes mellitus
(diabetes)
DOA date of admission; dead
on arrival
DOB date of birth
Dx diagnosis
drsg dressing
DSD dry sterile dressing
DT, DTs delirium tremens (“the
shakes” from alcohol
withdrawal)
ECG, EKG electrocardiogram
EEG electroencephalogram (measurement of
electric brain activity)
e.g. example
ENT ears, nose, throat
ERT estrogen replacement
therapy
est, EST estimate; electroshock
therapy
ETOH ethanol (alcohol)
FBS fasting blood sugar (a
lab test)
F/U FU follow up
FUO fever of unknown
origin
Fx fracture
G tube gastric tube (a
tube in the stomach)
GB gall bladder
GBS gall bladder series (a
type of xray of the
gut)
Medical Abbreviations and Symbols,
page 3
NC DSS Adult and Family
Services Section, November 1,
1998
GC gonorrhea
GERD gastroesophageal reflux disease
(a severe recurrent
heartburn
disorder)
GU genitourinary
gtts drops
gyn gynecology
hgb hct hemoglobin, hematocrit,
(both are blood cell
measurements)
HHA home health agency; or
home health aide
H2O water
HS, hs hour of sleep, or
at bedtime
ht height
Hx hx history
I & O intake and
output ( amount of fluid
taken in and urine
output)
ICF intermediate care
facility
ICU intensive care unit
ID incision and drainage (when
a scalpel is used to cut
& drain a
boil)
IDDM insulin dependent diabetes
mellitus
IM intramuscular
inj injection
IV intravenous
IVP intravenous pyelogram ( a
type of xray of the
kidneys and
bladder)
L lft lt left
L1, L2, L3 refers to the
lumbar section of the
spine
lab laboratory
liq liquid
LLQ left lower quadrant
LP lumbar puncture (spinal
tap)
LPN licensed practical
nurse
LRQ lower right quadrant
LUQ left upper quadrant
LV left ventricle
max maximum
meds medications
MI myocardial infarction (heart
attack)
mod moderate
MRI magnetic resonance
imaging
MS mitral stenosis; multiple
sclerosis; musculoskeletal
MVR mitral valve
replacement
N/C no complaints
NG, NGT nasogastric (tube)
Medical Abbreviations and Symbols,
page 4
NC DSS Adult and Family
Services Section, November 1,
1998
NIDDM non-insulin dependent diabetes
mellitus
noc night
norm normal
NPO nothing by mouth
NSAID nonsteroidal anti-inflammatory
drug
nsg nursing
OA osteoarthritis
OBS organic brain syndrome
occ occasional
OD right eye; overdose
OOB out of bed
OS left eye
OU both eyes
orth ortho orthopedic
os bone; opening; mouth
OV office visit
O2 oxygen
p after
P pulse
PA physician assistant
Pap pap smear ( a lab
test)
path pathology
pc, p.c. after meals
PDR physician’s desk reference (a
drug handbook)
PE pe physical exam
prn, p.r.n. as needed or
required
PROM passive range of
motion
PO po my
mouth
pt patient
PVC premature ventricular
contraction
PVD peripheral vascular
disease
ph pH hydrogen ion concentration
( a measure of the
acidity of a
substance)
q every
qam every am
qd every day
qod every other day
qh every hour
q2h, q3h, q4h every 2
hours, every 3 hours, every
4 hours
qhs every night (hour of
sleep)
qid four times a day
quad quadriplegic ( arms and
legs paralyzed)
R, rt right
Medical Abbreviations and Symbols,
page 5
NC DSS Adult and Family
Services Section, November 1,
1998
RA right atrium
re: about or regarding
rbc, RBC red blood
cell
reg regular
resp respiration or breaths
RLQ right lower quadrant
RN registered nurse
R/O, r/o rule out
ROM range of motion
RUQ right upper quadrant
RV right ventricle
Rx, RX treatment
s without
SA sinoatrial node
sl sublingual meaning under the
tongue
sm small
SOB short of breath
S/P, s/p status post (status
post an “event” , s/p MI,
s/p CVA, s/p GI
bleed)
spec specimen
spec grav, sp gr specific
gravity (urine test)
s & s, s/s signs and
symptoms
staph staphylococcus
stat immediately
STD sexually transmitted
disease
strep streptococcus
subq, subc subcutaneous
symp, Sx symptom
T temperature
T1, T2, T3 refers to the
thoracic section of the
spine
tab tablet, a tablet of
medication, a round pill
TB tuberculosis
THR total hip replacement
TIA transient ischemic
attack
tid three times a
day
TKR total knee replacement
T/O, t/o telephone order
TPR temperature, pulse, respiration
(the measurement of these
3
things)
tsp teaspoon measurement
TUR, TURP transurethral resection
(prostate gland surgery in
men)
Tx treatment
U/A, u/a urine analysis
Medical Abbreviations and Symbols,
page 6
NC DSS Adult and Family
Services Section, November 1,
1998
URI upper respiratory
infection
UTI urinary tract infection
VD venereal disease
VO, v/o verbal order
vs, VS, v/s vital signs
(temperature, pulse and respiration
measurements)
WBC, wbc white blood
cell
W/C wheel chair
WNL within normal limits
w/o without
wt weight
w/u work up
x times
y/o years old
yr year
Commonly Used Symbols
increase
decrease
~ approximately # number
@ at o
degree
> greater than < less
than
+ positive - negative
+, & and Ø
nothing, not, none
= equal to not equal
to
male female
one of something 2, 3 of
something
