University

 of  Pittsburgh   1  
Clinical  Terminology  for  International  and  U.S.  Students  
 
Week  2:   The  Clinical  Unit  and  Bedside  Environment  
 

Health  Care  Provider  Titles  

Abbreviation   Term   Description  
(Written)  
R.N.   Registered  Nurse   A  nurse  with  a  2-­‐year  associate  to  4-­‐year  bachelor  degree  or  advanced  
degrees.    Plans,  organizes  and  provides  direct  patient  care.  
C.C.R.N.   Clinical  Coordinator  Registered   RN  who  coordinates  patient  care  activities  including  patient  
Nurse  or  Clinician  Case  manager   education/discharge  and  supervises  RNs  and  team  members  delivering  
direct  patient  care.  
C.R.N.P.   Certified  Registered  Nurse   A  nurse  with  a  master’s  or  doctoral  level  education  and  advanced  
Practitioner   assessment  and  medical  diagnostic  skills.  
C.N.S.   Clinical  Nurse  Specialist   A  nurse  with  a  master’s  degree  often  combined  with  teaching,  clinical  
supervision  roles.  
N.A.  or  C.N.A.   Nursing  Assistant  or  Certified   A  technician  with  a  high  school  education  and  in-­‐hospital  training.    May  
Nursing  Assistant   earn  certification  with  additional  courses.  
C.N.L.   Clinical  Nurse  Leader   RN  at  master’s  level  provides  administrative  and  educational  leadership.  

Physician  (Doctor)   Dr.   Commonly  spoken  to  as  “Doctor”  or  written  as:  Dr.  Smith  redressed  
    wound.        
    Signature  or  name  tag  will  read:    John  Smith,  M.D.  
Medical  Doctor   M.D.  (written  only)  
P.A.   Physician  Assistant   A  professional  with  2-­‐6  years  of  education  after  high  school  with  
advanced  skills  for  assessment  and  medical  diagnostics.    Generally  
employed  by  a  physician.  Seen  most  often  on  a  surgical  unit.  
P.T.   Physical  Therapist   A  professional  with  a  master’s  degree  or  higher  and  expertise  in  
preservation  and  rehabilitation  of  body  movement  and  function.  
University  of  Pittsburgh   2  
Clinical  Terminology  for  International  and  U.S.  Students  
 
O.T.   Occupational  Therapist   A  professional  with  a  master’s  degree  and  expertise  in  upper  extremity  
fine  motor  skills  and  rehabilitation,  swallowing  and  balance  problems.  
R.T.   Respiratory  Therapist   A  professional  with  2-­‐4  years  of  post-­‐high  school  education  who  has  
expertise  in  the  care  of  the  respiratory  tract  and  use  of  respiratory  
equipment.  
S.W.  or  M.S.W.   Social  Worker   A  professional  with  a  master’s  degree  who  helps  patients  and  families  
obtain  government  and  state  services,  coordinates  discharge  plans,  and  
provides  counseling.  
University  of  Pittsburgh   3  
Clinical  Terminology  for  International  and  U.S.  Students  
 
 
 
 
 
 
 
 
Hospital-­‐Associated  Locations  
Abbreviation   Abbreviation   Term   Description  
(Written)   (spoken)  
                                                                                                             
Site  in  the  hospital  where  patients  receive  emergency  care.  
Emergency  
ER            E-­‐R  
-­‐or-­‐     Room  
-­‐or-­‐       -­‐or-­‐    
ED   E-­‐D   Emergency  Department  
 
     
OR   O-­‐R   Operating  Room   Where  surgery  is  performed.  

ICU   I-­‐C-­‐U   Intensive  Care   Where  patients  who  are  critically  ill  receive  highly  technical,  lifesaving  care.  
Unit  
CCU   C-­‐C-­‐U   Coronary  Care   Unit  specializing  in  care  of  patients  with  acute  coronary  problems  
Unit  
LTC   L-­‐T-­‐C   Long  Term  Care   Facility  that  provides  extended  nursing  care.  

PACU   PAC    -­‐  U   Post  Anesthesia   A  unit  where  patients  recover  from  anesthesia.    
Care  Unit    
LTACH   L-­‐  TACH   Long  Term  Acute   Special  care  hospital  or  unit  for  patients  who  are  chronically  acutely  ill.  For  exam
Care  Hospital   who  must  remain    on  a  respirator  or  with  a  tracheotomy.      
University  of  Pittsburgh   4  
Clinical  Terminology  for  International  and  U.S.  Students  
 
Health  Care  Practitioner  Notation    
Abbreviation   Term   Clinical    Note  Example  
(written)   (spoken)  
Pt   Patient   Pt  amb  to  BR.      
C/O   Complains  of   C/O  “stomach  upset”.  
BR   Bed  Rest   The  pt  complained  of  trouble  urinating  because  he  is  restricted  to  
BR  and  use  of  the  urinal.  
BR   Bathroom   Pt  needed  assistance  using  BR.  
OOB   Out  of  Bed   Dr.’s  orders:  OOB  as  desired.  
WNL   Within  normal  limits   Breath  sounds  WNL.  
TCDB   Turn,  cough  and  deep  breathe.   Encouraged  pt  to  TCDB.  
NKA   No  known  allergies   The  pt  says  NKA  but  wife  says  he  is  allergic  to  penicillin.  
S/P   Status  post   State  after  an  intervention  S/P  bowel  resection.  
HOB   Head  of  bed   Raise  HOB  to  30  degrees.  
amb   Ambulate  (walk)   Pt  refused  BR  order,  amb  to  toilet  refusing  assistance.  
 Cc      c  with  a  line  over  it   With       OOB  c  ̅c     assistance  
s  with  a  line  over  it-­‐or-­‐  w/o     Without   Amb  s   ̅       pain.  -­‐or-­‐  Amb  w/o  pain.  
Tx   Treatment   Lotion  Tx  for  pruritus  applied  to  pts  back  and  arms.  
sx   Symptoms   The  pts  only  sx  is  extreme  fatigue.  
dx   Diagnosis   dx  probably  appendicitis.  
DNR   Do  not  resuscitate  or  DNR   The  doctor’s  order  read:  DNR      She  said,  “Check  the  chart.  I  think  he  
has  a  D-­‐N-­‐R  order.”  
DNI   Do  not  intubate  or  DNI   Progress  note:  Discussed  DNI  with  pt.  
CMO   Comfort  Measures  Only  or  CMO   He  said,  “Family  has  family  agreed  to  stop  some  treatments  and  
institute  C-­‐M-­‐O.  “  
AMA   Against  Medical  Advice  or  AMA   Progress  note:  “Pt  left  hospital  AMA.”    She  reported,  “He  left  A  M  A.”  
D/C   Discontinue  or  DC   Dr.’s  order:  D/C  the  IV  now.    She  said,  “Please  D-­‐C  Mr.  Jones’  IV.”  
University  of  Pittsburgh   5  
Clinical  Terminology  for  International  and  U.S.  Students  
 
 

Clinical  Assessment  Abbreviations

Musculoskeletal  Activity  
Assessment  Abbreviations   Term      
(written)   (Spoken)  
ROM   Range  of  Motion  or  ROM   When  bathing  a  comatose   ROM  to  upper  and  lower  
patient,  put  each  joint  through   extremities.  
range  of  motion  
AROM   Active  Range  of   Range  of  movement  the  patient   AROM  limited  by  pain  to  50%  of  
Motion  or  AROM   can  perform.   normal.  
ADLs   Activities  of  Daily   A  part  of  nursing  assessment  is   Independent  in  all  ADLs  except  
Living  or  ADL’s   noting  what  ADL’s  the  patient  is   applying  socks  and  shoes.  
able  to  perform  independently.  

Neurological  (neuro)  System  

PEERLA   Pupils  equal,  round,  react  to   Neurological  evaluation  of  optic   Progress  note:  No  verbal-­‐
light  and  accommodation  or   nerve  function   izations.  PERRLA.      
Pearl  or  pearla  
LOC   Level  of   Degree  of  or  level  of  awareness   LOC  decreasing.  
Consciousness  or  LOC   of  self  or  surroundings  
A&O  x3   Alert  and  oriented  to  time,   Awareness  of  time,  place  and   A&O  x3.    No  c/o  pain.  
place  and  person  or  A&O  or   person  
A&O  x3  
       
University  of  Pittsburgh   6  
Clinical  Terminology  for  International  and  U.S.  Students  
 

Heart  and  Lungs  

NSR   Normal  Sinus   Normal  heart  beat  seen  on   No  C/O  chest  pain.  NSR.  R  24  
Rhythm  or  NSR   electrocardiogram  
BS  (written  only)   Breath  Sounds   Sounds  of  breath  heard  with  a   BS=rales  at  left  base  
stethoscope.  
SOB  (written)   Short  of  breath   Feeling  that  one  cannot  breathe   Progress  note:  Less  C/O  SOB.  
fully  or  comfortably   She  said,  “The  patient  is  short  
of  breath  with  slight  exertion.”  
PND     Paroxysmal  nocturnal  dyspnea   Becoming  short  of  breath  after   The  report  stated:  Pt  wakes  
Or  PND   lying  recumbent.   with  PND  and  opens  a  window.  
The  doctor  said,  “PND  may  
indicate  congestive  heart  
failure.”  

Gastrointestinal  System  
ABD  (written  only)   Abdomen   This  is  written  only  except  when   Abd  palpation  negative  for  pain.  
saying  “A-­‐B-­‐D  dressing.”  
N/V  (written  only)   Nausea  and  vomiting     No  n/v  

BM   Bowel  Movement  or  B-­‐M   Evacuation  of  feces  from  the   Progress  note:  BM  x  2.  
lower  intestine.   She  said,  “Check  this  B-­‐M.  Is  this  
melana?”  
BS  (written  only)   Bowel  Sounds   Sounds  made  by  movement  in   Progress  note:  BS  active  12  hrs.  
the  intestine  during  peristalsis.   S/P  colectomy.  
Usually  heard  with  a   The  doctor  asked,  “Are  bowel  
stethoscope.   sounds  active  yet?”    
GI       Gastrointestinal  or  “G-­‐I”   Esophagus,  stomach,  small  and   GI  workup  reveals  tumor  near  
large  intestines.   head  of  the  pancreas.  
University  of  Pittsburgh   7  
Clinical  Terminology  for  International  and  U.S.  Students  
 

Genito  Urinary  System  

GU     Genito  Urinary  or  “G-­‐U”     Will  do  GU  work  up  for  
hematuria.  
I  &  O   intake  and  Output  or  “I  and  O”   Measurement  of  any  liquid  taken  into  th   She  said,  “This  patient  has  
body  by  mouth  or  IV  and  measurement   severe  kidney  disease.  We  need  
of  all  fluid  leaving  the  body  including   a  very  accurate  I  and  O.”  
urination  or  vomiting,  etc.  
University  of  Pittsburgh   8  
Clinical  Terminology  for  International  and  U.S.  Students  
 

History  and  Physical  Examination  

Electronic  Medical  Records  (EMR)  

(Written  and      
spoken    unless  
otherwise  noted)  
H  &  P   History  and  physical   On  the  H  &  P  done  by  NP  Betty  Smith,  I  read  the  following  notes:  
 
CC:  Pain  left  lower  leg.  
HPI   History  of  present  illness    
HPI:  The  pt  was  well  until  24  hrs  ago  when  he  noticed  pain  and  swelling  in  
CC   Chief  complaint   the  posterior  left  lower  leg.    Reports  long  airplane  travel  of  over  12  hours  
(written  only)   prior  to  onset  of  pain.  

Hx   History     The  note  read:  The  pts  sx  of  pain  increase  with  walking.  No  hx  of  prior  
(written  only)   episodes  of  calf  pain.  No  H/O  blood  clotting  problems.  
The  NP  said,  “When  I  took  his  history,  his  only  symptom  was  leg  pain  and  
H/O   History  of     he  had  not  history  of  prior  phlebitis.”  
(written  only)  
PMH   Past  medical  history   The  N.P.’s  note  read:    PMH  is  notable  for  H/O  headache  occurring  on  left  side  
of  the  head.  
Did  you  find  out  if  there  is  any  past  medical  history  of  headache?  
ROS   Review  of  symptoms   The  N.P.  said,  “He  didn’t  mention  the  chest  pain  until  I  was  going  through  the  
review  of  systems.”  
As  I  read  the  EMR,  I  saw  ROS  with  the  many  systems  of  the  body  and  
symptoms  listed.  
 
  
 
Case  1  
Abbreviation   Term   Example  or  Explanation  
(Written  and  
Spoken)  
PPE   Personal  protective   Specialized  clothing  or  equipment  such  as  gloves,  mask,  eye  protection,  and  
equipment   gowns  for  protection  against  infectious  material.    Part  of  standard  or  universal  
precautions.  
2x2,  4x4   2  X  2  Surgical  dressings,   Sterile  gauze  and  cotton  cover  for  a  wound  or  incision.  The  most  common  are  
4  X  4  Surgical  dressings   square  and  measure  2  inches  (about  5  cm)  or  4  inches  (about  10  cm)  on  each  
side.  
ABD   Abdominal  Dressing   A  large  thick  more  absorbent  sterile  gauze  and  cotton  dressing  or  pad.  Size  
varies,  usually  6  inches  (15.4cm)  X  8  inches  (20.3  cm)  inches.  
Wound  VAC   Negative  Pressure  wound   The  use  of  a  mild  suction  device  that  employs  negative  pressure  or  suction  to  
therapy   remove  fluid  from  the  wound  and  improve  healing.  
NG  -­‐or-­‐  NG  tube   Nasogastric  tube   A  flexible  plastic  tube  that  enters  the  body  at  one  nostril  and  extends  to  the  
stomach.  Used  for  providing  nourishment  or  medication.  Also  used  for  
removing  stomach  contents  by  suction.  An  NG  tube  is  a  temporary  way  to  
administer  food  and  fluids  when  the  patient  is  unable  to  swallow.  
SCD   Sequential  Compression   A  machine  used  on  the  legs  of  immobilized  patients  to  prevent  pooling  of  
Device   venous  blood  in  the  lower  extremities  (or  to  increase  venous  blood  flow  from  
the  legs  to  the  heart).  
  
 
Case  2  
Abbreviation   Term   Example  or  Explanation  
(Written  and  
spoken)  
PEG  tube   Percutaneous  endoscopic   The  PEG  tube  gets  its  name  from  abbreviation  of  the  procedure  used  to  insert  
gastrostomy  tube   it:  Percutaneous  Endoscopic  Gastrostomy  (highlight  first  letters).  The  PEG  
tube  is  visible  on  the  upper  left  abdomen.  Food  and  medications  are  injected  
or  drained  into  the  stomach  through  the  feeding  tube.    Although  the  PEG  
tube  is  most  common,  other  tubes  provide  direct  access  to  the  
gastrointestinal  tract.  See  G-­‐tube,  J-­‐tube  and  GJ  tube.  
Trach   Tracheostomy   Opening  through  the  skin  of  the  throat  into  the  trachea  or  windpipe.  A  
tracheostomy  tube  is  place  in  the  opening.  Air  passes  from  the  tube  into  the  
lungs.  
Cath   Catheter   A  hollow  cylinder  that  allows  for  liquid  to  pass  through.    Commonly  used  to  
drain  fluid,  such  as  urine  out  of  the  body.    Also,  used  to  place  fluids  into  the  
body,  e.g.  peripheral  venous  catheter  (module  3).  
Foley   Foley  Catheter   An  indwelling  urinary  catheter  held  in  the  bladder  by  a  small  balloon  inflated  
after  insertion.    The  catheter  is  small  (fitting  into  the  urethral  or  a  vessel)  and  
then  is  connected  to  larger  tubing  that  leads  to  a  transparent  plastic  bag  for  
collection  of  urine.  
 
  
 
Case  3  
Abbreviation   Term   Example  or  Explanation  
 
NC   Nasal  cannula   Plastic  tubing  with  short  prongs  (small  tubes  leading  off  of  the  main  tube)  
(Usually  written)   (Usually  spoken))   that  fit  into  the  nostrils  for  delivery  of  oxygen  
T-­‐E-­‐D  hose  or   Antiembolic  Stocking   Elastic  stocking  used  to  control  swelling  and  reduce  the  risk  of  developing  
TED  hose  (written   blood  clots  in  the  legs  or  deep  vein  thrombosis.    Rarely  used  formal  name  is  
and  spoken)   thrombo-­‐embolism  deterrent  stocking  or  hose.