Medical Terminology

1.01 Identify abbreviations commonly used in the health care

setting.

Medical abbreviations

• Shortened forms of words• They are an efficient way of

communicating quickly and concisely with other health care workers.

• Health care workers use abbreviations to convey information about their patients/clients.

Medical abbreviations

• help save time and space on medical documents.

• Also known as short hand• usually just letters but #s are sometimes

used.

Examplesam (before noon)

H20 (water)

Medical abbreviations

• May be combined to give orders or directions

• Varies depending upon facility or culture

• Periods may or may not be usedExample: a.m. or am

Medical abbreviations

• Each individual is responsible for making sure that they are using the appropriate abbreviations for their agency.

• Incorrect / illegal abbreviations could lead to misunderstandings, confusion or anger.

Abbreviation Usage

• Be considerate when you use an abbreviation

• Your patients do not always know what the abbreviations mean.

Ex: NPO posted over the head of the bed (HOB)

• As a HCP you know what it means but the patient doesn’t , you need to explain to the pt. what it means.

Incorrect and illegal abbreviations

• Sometimes used by personnel due to not knowing facilities approved list.

• Ex: Jim is a FLK.• David Snow – 48 yoa SWM,

dyspnea, s.o.b., HA, chest pain & N & V.

Transcribe to abbreviated format

Suzanne to be admitted to the hospital through the emergency room department. She came in complaining of headache, difficulty breathing, and chest pain. She has a past history of heart attacks, stroke and high blood pressure. Orders are as follows:

1. Monitor blood pressure every two hours 2. Complete blood count, potassium, sodium

and magnesium levels3. Chest x-ray and magnetic resonance imaging

Abb. Written order

Suzanne adm. through ER dept. Pt. c/o HA, dyspnea, and chest pain. Past hx. Of MIs, CVA & HBP. Orders are as follows:1. ck BP Q2H2. CBC, K, Na and Mg levels3. Chest XR & MRI

Commonly used Abb.

• TPR & BP • ASAP• Stat• CA• HA• WNL• Ad lib

• am• Rx• tsp• q2h• mL• EEG • VS

Identification of common medical abbreviations

• abd - abdomen• amb - ambulate/walk• bid - twice a day• CCU - coronary care

unit or critical • CVA -

cerebrovascular accident / stroke

• po - by mouth

• OOB/oob - out of bed

• OR - operating room

• ER - emergency room

• PEDS - pediatrics• P.T. - physical

therapy

Discussion time and hands on practice.

FYI : You already use abbreviations.Ex: text messaging, email, time, etc…

References

• Health Careers Science Exploration Textbook – Chapter 7 pgs:

• NCDPI