3.4 Medical Terminology, Abbreviations, and Symbols
Key Takeaways
- Duty H of the Oklahoma 8607 blueprint opens with using common medical terminology, abbreviations, and symbols, and CareerTech publishes the exact abbreviation list its item writers draw from — including HS for at bedtime, QID for four times a day, and NPO for nothing by mouth.
- Frequency abbreviations are the highest-yield group: BID means twice daily, TID means three times a day, and QID means four times a day, so confusing TID with QID changes a care schedule by an entire administration.
- Word parts decode unfamiliar terms: the prefix hypo- means low or under, hyper- means high or over, the suffix -itis means inflammation, and -emia refers to a blood condition, so hyperthermia and hypothermia are opposite findings.
- A nurse aide may read and use approved abbreviations in documentation but must never invent shorthand, and abbreviations that create ambiguity in a resident's record should be spelled out.
3.4 Medical Terminology, Abbreviations, and Symbols
Core Clinical Mandate: Duty H: Demonstrate Basic Nursing Skills carries 16% of the Oklahoma 8607 written examination — 11 questions — and its very first listed sub-topic is "Use common and/or appropriate medical terminology, abbreviations, and symbols." This is a silent multiplier across the whole test. Oklahoma's own published sample items are written in shorthand: one asks about a resident with "sterile dressing changes TID." A candidate who cannot decode TID cannot answer a question about wound safety they otherwise know cold.
Why Shorthand Is a Safety Issue, Not Just Vocabulary
Clinical abbreviations exist to make a chart fast to scan during a shift change. That speed cuts both ways. BID, TID, and QID differ by a single letter and by an entire administration per day. NPO and PO are two letters apart and mean opposite things — nothing by mouth versus by mouth. A nurse aide who serves breakfast to an NPO resident scheduled for a swallow study has caused a real aspiration risk and a canceled procedure.
The nurse aide's job is to read these correctly and to use only approved abbreviations when documenting. Aides do not invent shorthand. If an abbreviation would be ambiguous to the next reader, spell the word out.
The Oklahoma Nurse Aide Abbreviation Set
CareerTech publishes the abbreviation, symbol, and acronym list its nurse aide assessments draw from. Learn these cold; grouping them by function makes them stick.
Frequency and Timing
| Abbreviation | Meaning | Bedside Consequence |
|---|---|---|
| BID | Twice daily | Two administrations or treatments per day |
| TID | Three times a day | Three per day — commonly tied to meals |
| QID | Four times a day | Four per day; the most easily confused with TID |
| HS | At bedtime | Evening-shift task; frequently a hygiene or comfort measure |
| AM | Morning | Day-shift care |
| PM | Afternoon | Evening care |
| PRN | As needed | Not scheduled; performed when the resident's condition calls for it |
Intake, Output, and Nutrition
| Abbreviation | Meaning |
|---|---|
| NPO | Nothing per oral — nothing by mouth, including water and ice chips |
| PO | Per oral — by mouth |
| I&O | Intake and output |
| mL | Milliliter |
| L | Liter |
| c | Cup |
| NG | Nasogastric (tube through the nose into the stomach) |
| PEG | Percutaneous endoscopic gastrostomy tube (surgically placed feeding tube) |
Measurement and Vital Signs
| Abbreviation | Meaning |
|---|---|
| T | Temperature |
| P | Pulse |
| R | Respirations |
| BP | Blood pressure |
| mmHg | Millimeters of mercury — the unit of blood pressure |
| F | Fahrenheit |
| ax (with temperature) | Axillary route |
| R (with temperature) | Rectal route |
| ° | Degree(s) |
| # | Pound(s) |
[!CRITICAL] "R" Is Context-Dependent In a vital-signs column, R means respirations. Written beside a temperature, R means the rectal route. Read the column heading before you interpret the letter — a rectal temperature charted as a respiratory rate is a documentation error that can trigger an unnecessary clinical workup.
Roles, Care, and Safety
| Abbreviation | Meaning |
|---|---|
| CNA | Certified nurse aide |
| CMA | Certified medication aide |
| LPN | Licensed practical nurse |
| RN | Registered nurse |
| ADL | Activities of daily living |
| POC | Plan of care |
| ROM | Range of motion |
| PPE | Personal protective equipment |
| CPR | Cardiopulmonary resuscitation |
| TED | Thromboembolism deterrent (anti-embolism stockings) |
| NKA | No known allergies |
| OTC | Over the counter |
| IV | Intravenous |
| HIPAA | Health Insurance Portability and Accountability Act |
| OSDH | Oklahoma State Department of Health |
Decoding Words You Have Never Seen
Exam items will use clinical terms that are not on any abbreviation list. Medical words are assembled from a prefix (beginning), a root (core meaning), and a suffix (ending). Learn the parts and you can decode the whole.
| Word Part | Meaning | Worked Example |
|---|---|---|
| hypo- | Low, under, below normal | Hypotension — low blood pressure |
| hyper- | High, over, above normal | Hyperthermia — elevated body temperature |
| brady- | Slow | Bradycardia — heart rate below 60 |
| tachy- | Fast | Tachypnea — respiratory rate above 20 |
| dys- | Difficult, painful, abnormal | Dysphagia — difficulty swallowing |
| a- / an- | Without, absence of | Apnea — absence of breathing |
| -itis | Inflammation | Dermatitis — inflammation of the skin |
| -emia | Blood condition | Anemia — deficiency of red blood cells |
| -pnea | Breathing | Eupnea — normal, easy breathing |
| -uria | Urine condition | Oliguria — scant urine output |
| -plegia | Paralysis | Hemiplegia — paralysis of one side of the body |
| -ostomy | Surgical opening | Colostomy — surgical opening into the colon |
| cardi/o | Heart | Cardiac — pertaining to the heart |
| derm/o | Skin | Dermal — pertaining to the skin |
| gastr/o | Stomach | Gastric — pertaining to the stomach |
| oste/o | Bone | Osteoporosis — porous, brittle bone |
Two prefix pairs generate a disproportionate share of exam distractors because they are opposites that look alike: hypo-/hyper- and brady-/tachy-. Hypoglycemia is low blood sugar; hyperglycemia is high blood sugar, and the CNA interventions differ completely.
Directional and Positional Terms
Skills-test scenarios and care plans use anatomical direction words that must not be guessed at:
- Anterior — front of the body; posterior — back of the body.
- Proximal — nearer the trunk; distal — farther from the trunk. A wrist is distal to an elbow.
- Lateral — toward the side; medial — toward the midline.
- Supine — lying flat on the back; prone — lying face down.
- Bilateral — both sides; unilateral — one side.
- Abduction — moving a limb away from the midline; adduction — moving it toward the midline. Remember adduction adds to the body.
Documentation Rules for Abbreviation Use
- Use only facility-approved abbreviations. Every facility maintains an approved list plus a "do not use" list. Never invent personal shorthand.
- Spell it out when ambiguity is possible. If a reader could reasonably interpret your shorthand two ways, write the word.
- Do not abbreviate the resident's own words. Direct quotes are recorded verbatim inside quotation marks.
- Never use abbreviations to blur an objective report. "Resident refused AM care" is acceptable; a vague abbreviation that hides what actually happened is not.
- Metric units are written exactly. Record intake in mL, blood pressure in mmHg, and weight in pounds using the # symbol only where the facility form calls for it.
A nurse aide reads the following in a resident's plan of care: "NPO after 2400 HS. I&O q shift." What does this instruct the aide to do?
A resident's order reads "Ambulate TID." A new nurse aide ambulates the resident four times during the day. What has occurred?
A nurse aide is told a resident has dysphagia and is at risk for hypothermia. Using medical word parts, what do these two terms describe?