Patient Assessment Abbreviations
65 abbreviations · part of Medical Abbreviations
Patient assessment abbreviations record vital signs, consciousness, pain scores, early warning scores and head-to-toe examination findings in nursing flowsheets, triage notes and physician exams. Many are standardized scales with published scoring rules, such as the Glasgow Coma Scale (GCS), FLACC or NEWS2, while others are bedside shorthand like PWD or NT/ND whose exact meaning depends on local charting policy. Recording the actual value, the scale used and the time measured matters more than the abbreviation itself.
| Abbreviation | Stands for | Description |
|---|---|---|
| AP | Apical pulse | Heartbeat counted with a stethoscope at the apex of the heart, normally at the fifth intercostal space in the left midclavicular line, for a full minute. |
| AVPU | Alert, voice, pain, unresponsive | Quick four-level consciousness check recording whether the patient is alert, responds only to voice, responds only to pain or is unresponsive. |
| Ax | Axillary | Route of temperature measurement in which the thermometer is held in the armpit, recorded as "Ax" after the reading. |
| BLE | Bilateral lower extremities | Both legs, used in assessment notes for findings like edema, pulses, strength or skin changes that apply to both sides. |
| BMI | Body mass index | Weight in kilograms divided by height in meters squared, used to screen adults for underweight, overweight and obesity. |
| BP | Blood pressure | Pressure of circulating blood against artery walls, written as systolic over diastolic in millimeters of mercury, such as 120/80 mmHg. |
| BPS | Behavioral Pain Scale | ICU pain tool for sedated, mechanically ventilated adults that rates facial expression, upper limb movement and compliance with ventilation from 1 to 4 each, giving a… |
| BS | Bowel sounds | Gurgling noises produced by movement of gas and fluid through the intestines, heard with a stethoscope over the abdomen. |
| BSA | Body surface area | Estimated total surface area of the body in square meters, calculated from height and weight. |
| BUE | Bilateral upper extremities | Both arms, used in assessment and therapy notes for findings such as strength, range of motion, tremor or IV restrictions that apply to both sides. |
| CAM-ICU | Confusion Assessment Method for the Intensive Care Unit | Delirium screening tool for ICU patients, including those on ventilators, that looks for an acute change or fluctuating mental status, inattention, altered… |
| CIWA-Ar | Clinical Institute Withdrawal Assessment for Alcohol, revised | Ten-item scale scoring alcohol withdrawal signs such as tremor, sweating, anxiety, agitation, nausea, hallucinations and headache, with a maximum of 67. |
| CMS | Circulation, motion, sensation | Neurovascular check of a limb, often after fractures, casting, splinting or orthopedic surgery, assessing color, warmth, pulses and capillary refill, the ability to… |
| COWS | Clinical Opiate Withdrawal Scale | Eleven-item clinician scale measuring opioid withdrawal signs such as resting pulse, sweating, restlessness, pupil size, yawning, runny nose, gooseflesh and anxiety. |
| CPOT | Critical-Care Pain Observation Tool | Behavioral pain tool for critically ill adults who cannot self-report, scoring facial expression, body movements, muscle tension and either ventilator compliance or… |
| CRT | Capillary refill time | Time it takes for color to return to a nail bed or skin after firm pressure is released, a quick bedside sign of peripheral perfusion. |
| CTA | Clear to auscultation | Lung exam finding that breath sounds are normal, with no crackles, wheezes or rhonchi heard through the stethoscope. |
| CTAB | Clear to auscultation bilaterally | Lung exam finding that normal breath sounds are heard throughout both lungs, without added sounds. |
| CVAT | Costovertebral angle tenderness | Pain when the area over the kidney, where the lowest rib meets the spine, is pressed or tapped with a fist. |
| EOMI | Extraocular movements intact | Eye exam finding that the eyes move fully and together in all directions of gaze, usually tested by following a finger in an H pattern. |
| FLACC | Face, Legs, Activity, Cry, Consolability | Observational pain scale for young children and nonverbal patients, scoring five behaviors from 0 to 2 each for a total of 0 to 10. |
| GCS | Glasgow Coma Scale | Standard score of consciousness combining eye opening (1 to 4), verbal response (1 to 5) and motor response (1 to 6), for a total of 3 to 15. |
| HC | Head circumference | Measurement around the largest part of the head, just above the eyebrows and ears and around the back, recorded for infants and young children and plotted on growth… |
| HEENT | Head, eyes, ears, nose, throat | Section of the physical examination and review of systems covering the head and face, eyes, ears, nose, sinuses, mouth and throat. |
| HR | Heart rate | Number of heartbeats per minute, measured from a pulse, cardiac monitor or ECG. |
| Ht | Height | Standing height, recorded in centimeters or inches, used with weight for BMI, drug dosing, kidney function estimates and ventilator settings based on predicted body… |
| LAD | Lymphadenopathy | Enlarged or abnormal lymph nodes found on examination or imaging, described by location, size, tenderness and consistency. |
| LLE | Left lower extremity | The left leg from hip to toes, recorded to locate wounds, edema, fractures, pulses or neurovascular findings, and in weight-bearing and positioning orders. |
| LOC | Level of consciousness | Degree of a patient's alertness and responsiveness, described with terms such as alert, lethargic, obtunded, stuporous or comatose, or scored with AVPU or the Glasgow… |
| LUE | Left upper extremity | The left arm from shoulder to fingers, recorded to locate IV lines, injuries, swelling, weakness or arm restrictions. |
| MAE | Moves all extremities | Neurological screening finding that the patient can move both arms and both legs on command or spontaneously. |
| MAEW | Moves all extremities well | Charting phrase indicating the patient moves both arms and both legs with apparently normal, symmetric strength. |
| MEWS | Modified Early Warning Score | Bedside score combining vital signs, and in many versions level of consciousness and urine output, into a single number that signals clinical deterioration on general… |
| MMM | Moist mucous membranes | Physical exam finding that the inside of the mouth is moist, used as a quick bedside sign of adequate hydration. |
| NABS | Normoactive bowel sounds | Abdominal auscultation finding of normal gurgling bowel sounds, roughly every few seconds, indicating ordinary intestinal activity. |
| NCAT | Normocephalic, atraumatic | Head exam finding meaning the skull is of normal size and shape and shows no signs of injury such as bruising, swelling, lacerations or deformity. |
| NEWS2 | National Early Warning Score 2 | UK standard track-and-trigger score that grades respiratory rate, oxygen saturation, use of supplemental oxygen, systolic blood pressure, pulse, consciousness and… |
| NIBP | Noninvasive blood pressure | Blood pressure measured with an external cuff, usually by an automated oscillometric monitor, as opposed to an arterial line inserted into an artery. |
| NRS | Numeric rating scale | Pain scale asking patients to rate their pain from 0 (no pain) to 10 (worst pain imaginable). |
| NT/ND | Nontender, nondistended | Abdominal exam finding that the abdomen is not painful to touch and is not swollen. |
| NVI | Neurovascularly intact | Exam finding stating that blood flow, sensation and movement distal to an injury, cast or surgical site are normal. |
| OPQRST | Onset, provocation, quality, region/radiation, severity, time | Mnemonic for questioning a patient about pain or another symptom: when it started, what makes it better or worse, what it feels like, where it is and spreads, how bad… |
| P | Pulse | Rate of palpable arterial beats per minute, written as "P" in vital-sign strings and older graphic charts. |
| PAINAD | Pain Assessment in Advanced Dementia | Observational scale for people with advanced dementia, rating breathing, negative vocalization, facial expression, body language and consolability from 0 to 2 each, for… |
| PEWS | Pediatric Early Warning Score | Scoring system that tracks behavior, cardiovascular status and respiratory status in hospitalized children to identify those deteriorating and needing escalation. |
| POSS | Pasero Opioid-Induced Sedation Scale | Nursing tool rating sedation in patients receiving opioids: S (sleeping, easy to arouse), 1 (awake and alert), 2 (slightly drowsy), 3 (frequently drowsy, drifts off… |
| PP | Pulse pressure | Difference between systolic and diastolic blood pressure, normally about 40 mmHg in a resting adult. |
| PWD | Pink, warm and dry | Skin assessment shorthand meaning normal color, temperature and moisture, suggesting good perfusion. |
| RA | Room air | Breathing ordinary air without supplemental oxygen, about 21 percent oxygen at sea level. |
| RASS | Richmond Agitation-Sedation Scale | Ten-point scale from +4 (combative) to -5 (unarousable), with 0 meaning alert and calm, used in intensive care to target sedation depth and screen for delirium. |
| RLE | Right lower extremity | The right leg from hip to toes, used to specify the site of findings, wounds, fractures, pulses or weight-bearing restrictions. |
| RR | Respiratory rate | Number of breaths taken per minute, counted by watching chest rise for 30 to 60 seconds. |
| RUE | Right upper extremity | The right arm from shoulder to fingers, used in assessment, procedure and imaging notes to specify location. |
| SpO2 | Peripheral oxygen saturation | Percentage of hemoglobin carrying oxygen, measured noninvasively with a pulse oximeter clipped to a finger, ear or forehead. |
| T | Temperature | Body temperature written in vital-sign strings as "T", with the route (oral, tympanic, temporal, axillary or rectal) and unit noted. |
| TA | Temporal artery temperature | Temperature measured by passing an infrared scanner across the forehead over the temporal artery, widely used in clinics, pediatrics and emergency triage because it is… |
| Tmax | Maximum temperature | Highest temperature recorded over a stated period, usually the previous 24 hours, reported on rounds and in progress notes to show the fever pattern at a glance. |
| TPR | Temperature, pulse, respiration | Grouping of three basic vital signs recorded together, especially in older charting systems, on paper graphic sheets and in veterinary practice. |
| TTP | Tender to palpation | Exam finding that pressing on an area causes pain, recorded with the exact location, such as the right lower quadrant or a specific joint line. |
| UTA | Unable to assess | Flowsheet entry used when a nurse cannot complete part of an assessment, for example orientation in a sedated patient or pain score in a nonverbal patient. |
| VAS | Visual analog scale | Pain or symptom measure in which patients mark a point on a 100 mm line anchored by "no pain" and "worst pain imaginable"; the distance in millimeters becomes the score. |
| VS | Vital signs | Core physiological measurements checked to judge a patient's basic condition: temperature, pulse, respiratory rate and blood pressure, with oxygen saturation and pain… |
| VSS | Vital signs stable | Summary phrase stating that a patient's vital signs are within acceptable ranges and have not changed significantly. |
| WOB | Work of breathing | Effort a patient uses to breathe, judged by rate, depth, accessory muscle use, nasal flaring, retractions, grunting and the ability to speak in full sentences. |
| Wt | Weight | Body weight recorded in kilograms or pounds, used for drug dosing, nutrition and fluid status. |
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