This nursing abbreviation list explains the shorthand that fills shift assessments, admission notes, handoff reports and visit summaries. These are the letters a nurse, aide or physician writes dozens of times a shift, and the ones a patient meets first when opening a portal note.
The chart note decoder on this page lets you paste a line from your own paperwork and see every covered abbreviation highlighted with its meaning. Below it, the terms are grouped by the part of the chart where they live, followed by a worked handoff example and tips for students.
At a glance
Covers
Note sections, exam findings, activity orders, code statusWhere you see it
Progress notes, flowsheets, handoff reports, visit summariesError-prone example
D/C, which can mean discharge or discontinueLocal rules
Each facility approves its own listRelated hub
The parts of a chart and their labels
Most clinical notes follow a predictable outline, and the section headings themselves are abbreviated. Knowing the outline tells you what kind of information comes next, which makes the shorthand inside each section easier to guess correctly.
| Term | Meaning | What sits under it |
|---|---|---|
| SOAP | Subjective, objective, assessment, plan | A four part layout for progress notes |
| H&P | History and physical | The full admission write up |
| HPI | History of present illness | How the current problem started and changed |
| PMH | Past medical history | Earlier conditions and surgeries |
| ROS | Review of systems | Symptom questions, body system by body system |
| C/O | Complains of | The main reason for the visit |
| DX | Diagnosis | The condition the team names |
History notes also use HX for history and TX for treatment, so a line such as "hx of asthma" simply means a past history of asthma.
Exam and assessment shorthand
Assessment terms record what the nurse or clinician saw, heard and measured. Many of them are normal findings written as a short phrase, so a long string of letters often means nothing unusual was found.
| Term | Meaning |
|---|---|
| A&O | Alert and oriented, often followed by x3 or x4 |
| NAD | No acute distress |
| VSS | Vital signs stable |
| WNL | Within normal limits |
| PERRLA | Pupils matched in size and round, reacting to light and to near focus |
| CTAB | Lungs clear to auscultation on both sides |
| RRR | Heart at a regular rate and rhythm |
| SOB | Shortness of breath |
| DOE | Breathlessness brought on by exertion |
| N/V | Nausea and vomiting |
| GCS | Glasgow Coma Scale, scored from 3 up to 15 for responsiveness |
Orders for activity, diet and status
Orders tell the whole team what a patient may do, eat and expect. They often appear on a whiteboard in the room as well as in the chart, which is how families tend to meet them.
| Term | Meaning |
|---|---|
| NPO | Nothing by mouth (nil per os) |
| OOB | Out of bed |
| WBAT | Weight bearing as tolerated |
| BRP | Bathroom privileges |
| HOB | Head of bed, as in HOB raised 30 degrees |
| ADL | Activities of daily living, such as bathing and dressing |
| NKDA | No known drug allergies |
| DNR | Do not resuscitate |
A code status term such as DNR records a decision made between the patient, family and physician. If you have questions about it, the physician or charge nurse is the right person to ask.
Reading a nursing abbreviation list against a real handoff
A real handoff squeezes a whole patient into a sentence or two. The sample below is unpacked term by term.
Shift report: "78 yo M s/p fall, A&O x4, VSS, NPO p MN for CT, OOB w/ assist x1." This reads: a 78 year old man after a fall (S/P means status post), alert, and oriented to self, location, date and the situation, vital signs stable, nothing by mouth after midnight before a CT scan, and out of bed with help from one staff member.
The small letters matter as much as the capitals. A lower case p with a line over it means after, w/ means with, and x1 tells you how many staff are needed.
Shorthand that is easy to misread
D/C is the classic problem. It can mean discharge or discontinue, so an order like "D/C IV" might be read two ways; ISMP lists it as error-prone and recommends writing the word out. PT may mean patient, physical therapy or prothrombin time, and CMS in a nursing note usually means circulation, motion and sensation rather than anything administrative.
Some bedside forms belong to other sections of the site. Dosing terms such as PRN and HS are covered with medicine orders, and lab names such as CBC sit in the tests and scans hub.
These meanings describe common charting practice in general. What a particular note says about your own care is best explained by whoever wrote the entry.
Learning nursing abbreviations as a student
- Ask for your facility's approved list on day one; it overrides any general reference.
- Learn terms by note section rather than alphabetically, so each one has a home.
- Write out anything on a do-not-use or error-prone list, even if you see others shorten it.
- When a short form is unfamiliar, ask the writer instead of guessing.
The self-study plan and the practice quiz help with the longer words behind the letters. Diagnoses that turn up in the assessment are grouped in the conditions hub.
Frequently asked questions
What does A&O x4 mean in a nursing note?
It means the patient is alert and oriented to four things: who they are, where they are, the time, and the situation. A lower number, such as x2, means fewer of those were answered correctly.
What does NPO mean before surgery?
NPO means nothing by mouth, from the Latin nil per os. The exact start time and any exceptions, such as sips with medicines, are set by the surgical team, so follow their written instructions.
Is there an official nursing abbreviation list?
There is no single national list of approved terms. Each hospital approves its own, and facilities accredited by The Joint Commission also avoid its do-not-use forms. If you need the right abbreviation for nursing documentation at your site, that local list is the one to use.
Why do nurses write WNL so often?
WNL, within normal limits, is a quick way to record a normal finding. Many facilities prefer the actual finding to be written, since a bare WNL does not show what was checked.
What does SOB mean in a chart?
In a medical record SOB means shortness of breath. It is a symptom, often paired with DOE, the version that appears during activity.