Medical Chart Glossary with Abbreviations and Definitions
Most of the times when you go to the hospitals and the doctor writes a prescription for you, you can hardly read it, and if you do, it doesn’t make sense! They often do this funny scribble containing important information that they would like you to reference, regarding your health condition or your medical history. It is made up of abbreviations and jargon, which leaves you wondering or wishing you knew what they meant.
Usually, there is no standard list, or an approved one for healthcare providers to use while searching for the abbreviations or acronyms. It is, therefore, vital to have a comprehensive context in which the terms have been used. They can cover instructions or myriads of conditions. Here is a short list of some of the commonly used medical terms, acronyms and abbreviations with their definitions.
Medical Terms and Abbreviations
Short form of ‘ante cibum,’ which means before meals. Used on prescriptions to indicate taking medicine(s) before eating.
Used as an index of the disease state to mean albumin to globulin ratio.
Short form of Anterior Cruciate Ligament. It is the commonest ligament injury to the knees. The ligament can sprain or tear completely from a traumatic experience or as a result of degeneration.
Used to refer to the antibodies.
Short form of at liberty. An ad lib order means that the patient has been allowed to move, for example, out of bed.
Attention deficit hyperactivity disorder is a mental health condition, characterized by impulse control, excessive activity, or being distracted.
Short form of an adverse reaction from medication. This is especially the case if a patient is taking medication for the treatment of high blood pressure disease.
Stands for above the knee amputation, a surgical procedure for the removal of the lower limb.
Used to refer to a patient’s condition of not producing urine. An anuric person is occasionally critical and dialysis is mandatory.
Alive no evidence of disease. Refers to a report that shows that the patient arrived in the emergency room without any evidence of disease.
Antidiuretic hormone. It is a hormone often used to treat diabetes insipidus, also used for stomach surgery before x-rays of the stomach.
These are medications used to control vomiting.
Acute respiratory distress syndrome. A condition in which the lung’s air sacs collect fluid, leading to the organs being deprived oxygen.
Acute renal (kidney) failure. A condition in which the kidneys fail to filter waste.
Atherosclerotic cardiovascular disease. It is a form of a heart disease that leads to the build-up of fats, and other substances including cholesterol in or on the walls of the artery.
Twice daily. This is a direction for the patient to take medicine twice a day.
Short form standing for blood. On a prescription, it means that blood was visible on the patient’s results.
This is an informal term referring to the elevated level of band forms of white blood cells.
When a tumor is not cancerous, it is referred to as a benign tumor.
Used to make reference to both bases of the lungs. If, for example, someone with a disease like pneumonia in both lungs, it is said they have abnormal bibasilar breath sounds.
Below the knee amputation. Refers to the surgical removal of part of the limb below the knee.
Stands for the basic metabolic panel. It is a blood test ordered by healthcare providers and it consists of biochemical tests for chloride, sodium, potassium, carbon dioxide, creatinine, and glucose.
Blood pressure. It is a vital sign often tested as part of the physical examination.
Borderline personality disorder. It is a mental disorder characterized by unstable moods, relationships, or behavior.
Bilateral salpingo-oophorectomy. BSO performed as part of a total abdominal hysterectomy, the removal of the uterus and the cervix, and it consists of the removal of the two ovaries and the adjacent oviduct.
Culture and sensitivity. These are tests conducted to detect germs, culture, and the appropriate medication that will work best to treat the infection or illness, sensitivity.
Complaint of. A common term used by healthcare providers to note a concern expressed by patients.
Clostridium difficile. A small intestine bacteria.
Capsule. Refers to a gelatinous oral dosage.
Used to refer to cancer or carcinoma.
Coronary artery bypass graft. It is a type of surgery aimed at improving the blood flow to the heart. CABG is used to treat those with severe heart disease.
Complete blood count, it is also known as complete blood cell count, full blood count, or full blood exam. It gives information about a patient’s cells in the blood.
Chief complaint. Refers to a patient’s main or priority concern
Stands for a complete dental evaluation, which is an oral examination as a benchmark of your overall health.
Cubic centimeters. A unit for the measurement of the volume of fluids.
Chemistry panel. A chem panel refers to a test conducted to determine the status of the electrolytes, the kidneys, as well as the liver.
Continuous positive airway pressure. It is a therapy solution for sleep apnea that involves a patient wearing a face or a nasal mask.
Chronic obstructive pulmonary disease. Refers to a group of diseases that makes it difficult for one to breathe because of blocked airflow.
Chemotherapy. One of the therapeutic treatments for patients with cancer.
Cerebrovascular accident. Known simply as stroke. It occurs due to the interruption of the brain’s blood supply, leading to damage.
D/C or DC
Discontinue or discharge. Used to give directions for discontinuing, for example, a medication or discharge a patient from the hospital.
Ductal Carcinoma In Situ. This is one of the forms of breast cancer.
Differential diagnosis. This is a type of diagnosis that involves considering several diagnostic possibilities to detect the type of cancer present in a patient.
Degenerative joint disease. It is another variant name of osteoarthritis.
Diabetes mellitus. A group of diseases that results to high blood glucose, too much sugar in the blood.
DNC, D&C, or D and C
Dilation and curettage. Refers to the widening of the cervix and the surgical removal of the uterus lining by scooping or scrapping.
Do not resuscitate. Refers to a specific order given not to artificially revive a patient. If this order is given, if the situation is critical and no code blue is called, they are not to be resuscitated.
Dyspnea on exertion. Refers to difficulty in breathing when one is exercising or is doing an activity.
Deep tendon reflexes. This is part of the neurological exam performed by doctors through the banging of tendons using a rubber hammer.
Deep venous thrombosis. Refers to a condition where a blood clot occurs deep in veins, usually in the leg.
Electroconvulsive therapy. One of the procedures used to control convulsions, seizures.
Fracture. Refers to a break in the bone or the cartilage as a result of trauma or a disease like osteoporosis.
Gram. It is a unit of measuring weight.
This is a medical slang, which means “get out of my emergency room.”
Graft vs. host disease. This is a condition that occurs when the donor stem cells or the bone marrow attack the recipient.
Use to refer to drops.
Hemoglobin and hematocrit. A low H&H signifies a presence of anemia. Long-term smoking, polycythemia rubra vera may elevate the H&H in people who have lung disease.
History and physical examination. It is a reference document that offers a detailed information of the patient’s history and findings when he or she is admitted.
At bedtime. It is a prescription that directs one to take medication at bedtime.
H/O or h/o
History of. Used to denote a previous event that occurred.
Hormone replacement or hormone replacement therapy. It is a form of treatment used to control estrogen and progesterone in women during menopause.
Hypertension. This is a condition in which the blood exerts too much pressure on the artery.
Incision and drainage. This is a clinical lancing, which is a minor surgical procedure to release pus or pressure that is built up under the skin.
Inflammatory bowel disease. Refers to an ongoing inflammation of the digestive system.
Implantable cardioverter defibrillator. It is a device implanted inside the body, used for performing defibrillation, cardioversion, and heart pacing.
Intensive care unit. A hospital’s special department or a healthcare facility providing intensive care and treatment medicine.
Intramuscular. One of the alternative method for medical administration, especially injection to the muscles.
Impression. This is a conclusive summary made by a healthcare provider about a patient’s condition.
Intensive therapy unit. See ICU
In the laboratory. Refers to those procedures occurring in the in a lab vessel or a controlled environment.
In the body. Procedures tested within or in the body.
Idiopathic pulmonary fibrosis. A lung disease that leads to scarring of the lungs for an unknown reason.
Used to refer to the joint.
Potassium. One of the electrolytes frequently tested in intensive care.
Chemical formula for potassium chloride.
Lobular Carcinoma In Situ. An area(s) with abnormal cell growth, which places one at a greater risk of developing breast cancer.
Low back pain. It is among the commonest medical complaints that affect the lumbar region.
Left lower quadrant. Used to describe a position, for example, when one is experiencing diverticulitis pain, it is felt in the left lower quadrant of the abdomen.
Left upper quadrant. Used the same way as LLQ
Medial collateral ligament. One of the four ligaments located on the inner side of the knee joint.
Milligrams. Another base unit for mass.
Medical history. This is information collected by the doctor to get relevant information, which is important in the management or the determination of a patient’s diagnosis.
Milliliters. It is another unit of volume.
Mitral valve prolapse. Referring to the heart’s valves on the upper and lower left chambers not closing properly.
Nausea or vomiting. Used to refer to the two occurring frequently.
Nursing care plan. A plan of actions taken by nurses while caring for a patient.
Nothing by mouth. It is a medical instruction that means withholding food especially when one wants to undergo a surgery that requires anesthesia and are required not to eat anything prior to the procedure.
Normal sinus rhythm of the heart. Refers to the normal heart beats and rate, which usually falls between 60 and 100 beats a minute.
Ova and parasites. This is a test carried out on a patient’s stool to determine the presence of an infection for cases like chronic diarrhea.
Used to mean the right eye.
Used to mean the left eye.
Refers to both the right and the left eyes.
Open reduction and internal fixation, such as with the surgical implementation of implants for repair purposes.
Pulse. Part of the physical examination as one of the vital signs of determining a heart rate.
After meals. An instruction to take two tablets after eating.
By mouth. From the Latin words per os. Used to describe an oral treatment.
Means as needed. It is an instruction to take medicine only when need arises, for example, while experiencing pain
Stands for posterior cruciate ligament. One of the four ligaments of the knee, connecting the posterior region of intercondylar and the condylar.
Progressive disease. Used to indicate a course of a spread, worsening, or growth of a disease or an illness.
Pupils equal, round, and reactive to light and accommodation. It is an eye exam used in the determination of how well the cranial nerves work.
Pulmonary function test. An examination to determine the status of the functioning of lungs.
Platelets. A blood-forming element along with erythrocytes and white blood cells.
Point of maximum impulse. This is the point where the heart beats against the chest, and it is usually felt during an examination.
Premenstrual syndrome. Symptoms occurring in women during ovulation and a period.
Parathyroid hormone. Also known as parathormone, or parathyrin, and is secreted by the parathyroid glands. It is used in bone remodeling.
Post-traumatic stress syndrome. A condition where one fails to recover after a traumatic event.
Peptic ulcer disease. Commonly known as stomach ulcers. Characterized by sore linings in the digestive tract, including the stomach, esophagus, and the ileum.
Each day. Instruction to take medication on a daily basis.
Four times daily. Means using medicine four times in a day.
Every 2 hours. Instructions to take medicine after every two hours.
Every 3 hours. Take medicine every 3 hours.
Each morning. Instruction to take medicine every morning
At each bedtime. For example, taking medicine each bedtime.
Every other day. Used to mean taking the prescribed meds every other day.
Each evening. Taking medicine every evening.
Rheumatoid arthritis. A type of disease that affects the joints.
Respiratory distress syndrome. A breathing disorder, usually in infants due to immature lungs.
Rule out. Used by doctors to show eliminated or excluded diagnoses while trying to find the correct ones.
Right lower quadrant. Used to indicate position. For example, in the right lower quadrant of the abdomen is the appendix.
Review of systems. It is a technique used to elicit a patient’s medical history.
Right upper quadrant. Used to indicate position, for instance, the liver is located on the right upper of the abdomen.
Status post. Used to simply mean that “the patient has had this in the past”
Season affective disorder. A mood disorder or a depression that occurs the same time each year.
Shortness of breath. Refers to difficulty in breathing.
Subcutaneous. Pertains an instruction while injecting into the fatty tissue for treatment or medication.
Temperature. It is taken as a vital sign during a physical examination.
Tonsillectomy and adenoidectomy. A surgery for the removal of tonsils.
Three times daily. Instructions to take medicine three times every day.
Tablet. Refers to the solid dosage unit prescribed by healthcare providers.
Total abdominal hysterectomy. TAH is a surgical procedure for the removal of the uterus and the cervix.
Total hip replacement. Refers to a procedure for the removal and replacement of damaged cartilage or bone with a prosthetic one.
Total knee replacement. A surgical procedure that involves the replacement of the knee with an artificial joint.
Temporomandibular joint. Refers to the two joints that connect your jawbone with the skull.
UA or u/a
Urinalysis. It is a typical medical diagnosis that involves conducting tests on a patient’s urine.
Upper limits of normal. It is a limit of the reference range used in the interpretation of test results for a patient.
Upper respiratory infection. It is a viral infection that affects the airways, the nose, and the throat.
As directed. Refers to taking medication as directed by a medical professional.
Urinary tract infection. Refers to any infection that affects either the bladder or the urethra.
Vital signs are stable. This is an indication that the patient is doing well.
Used to refer to a patient’s weight.
Radiotherapy, external. It is a radiation therapy used as part of cancer treatment.