West Side Community Health Services
West Side Community Health Services
Manual Clinical Page 1 of 13
Subject Abbreviations Category Medical
Effective 1/00
Approval Medical Director
_X_ Policy ___ Procedure Executive Director
Policy:
West Side Community Health Services uses standardized abbreviations and symbols in its medical record documentation:
AAA abdominal aortic anuerysm
AAROM Active assistive range of motion
AB abortion
ABDHyst Abdominal Hysterectomy
ABG arterial blood gas
ac before meals
AC acromioclavicular
ACEI angiotensive converting enzyme
ACTH Adrenocorticotrophic hormone
ACL Anterior cruciate ligament
ad. to; up to
ad lib as much as needed; as desired
ADA diet American Diabetic Association diet
ADAP Alcohol and Drug Abuse Program
ADAT advance diet as tolerated
ADC Adult Detention Center
ADH Anti-diuretic Hormone
ADL Activities of daily living
adm Admission
AFib Atrial Fibrillation
AFB Acid Fast Bacilli
AFO Ankle foot orthosis
AGA Appropriate for gestational age
A/G ratio albumin-globulin ratio
AI aortic insufficiency
AK above the knee
AKA above the knee amputation
Alb. albumin
ALS amyotorphic lateral sclerosis
AM morning
AMA against medical advice
amt. amount
anat. anatomy; anatomical
ant. anterior
ante before
A&P auscultation and percussion
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Category Medical
Subject Abbreviations Page 2 of 13
A-P anterior/posterior
aptt. activated partial thromboplastin time
aq aqueous
ARC AIDS related complex
ARDS adult respiratory distress syndrome
AROM active range of motion
AROM artificial rupture of membranes
AS aortic stenosis
ASA aspirin
ASCVD atherosclerotic cardiosvascular disease
ASD atrial septal defect
ASHD atherosclerotic cardiovascular disease
A-V arteriovenous
AV arterioventricular
AVR aortic valve replacement
BAER’s brain stem auditory evoked responses
BAD bipolar affective disorder
BAL bronchial alveolar lavage
BCG vaccine for TB
BHCG beta human chorionic gonadotropin
b.i.d. twice a day
BK below the knee (amputee)
BKA below the knee amputation
BM bowel movement
BMR basal metabolic rate
BP blood pressure
BPD bronchopulmonary dysplasia
BPH benign prostatic hypertrophy
BRAT banana, rice, apples, toast
BRBPR bright red blood per rectum
BRP bathroom privileges
BS blood sugar
BS bowel sounds
bs breath sounds
BSF basilar skull fracture
BSO bilateral salpingo-oopherectomy
BTL bilateral tubal ligation
BUN blood urea nitrogen
Bx biopsy
c with
centigrade
C cervical
Ca calcium
ca cancer; carcinoma
CAB coronary artery bypass
CABG coronary artery bypass graft
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 3 of 13
CAD coronary artery disease
cap. capsule
C.A.T. computerized axial tomography; CT
cath catheter; catheterization
CBC complete blood count
CC chief complaint
cc cubic centimeter
CD chemically dependent
CEA carcino-embryonic antigen
cg centigram
CHF congestive heart failure
CHI closed head injury
chole cholecystectomy
Cl chloride
cm centimeter
CMG cystometrogram
CMS capillary filling, movement and sensation
CMV cytomegalovirus
CNS central nervous system
c/o complains of
CO carbon monoxide
CO2 carbon dioxide
COPD chronic obstructive pulmonary disease
CPD cephalopelvic disproportion
CPR cardiopulmonary resuscitation
CS C-section
CSF cerebrospinal fluid
C-spine cervical spine
C.T. computerized tomography – CAT
CT chest tube
cu cubic
CUG cystourethrogram
CV cardiovascular
CVA cerebrovascular accident
CVP central venous pressure
CW consistent with
CXR chest X-ray
d/c discontinued
D/C discharge
D&C dilatation and curretage
DAT diet as tolerated
DBP diastolic blood pressure
decub decubitus
DIC disseminated intravascular coagulation
diff differential blood count
dil diluted
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Category Medical
Subject Abbreviations Page 4 of 13
DIP distal interphlangeal
DJD degenerative joint disease
DM diabetes mellitus
DNR/DNI do not resuscitate/intubate
DOA dead on arrival
DOB date of birth
doe dyspnea on exertion
DTR deep tendon reflexes
DT diptheria tetanus
DT’s delerium tremens
DVT deep vein thrombosis
Dx diagnosis
EAB elective abortion
EBL estimated blood loss
ECG electrocardigram
ECT electroconvulsive threrapy
ED emergency department
EDC estimated date of confinement
EEG electroencephalogram
EENT eye, ear, nose and throat
EFM external fetal monitor
EFW estimated fetal weight
e.g. for example
EKG electrocardiogram
EMG electromyogram
EMS emergency medical device
ENG electronystgmogram
ENT ear, nose and throat
EOM extraocular movement
ER emergency room
ERCP endoscopic retrograde cannulation of pancreatic duct
esp. especially
ESR erythrocyte sedimentation rate
EST electroshock therapy
et and
ETOH ethyl alcohol; ethanol
ETT endotracheal tube
exam examination
exp exploratory
ext extremities
F Fahrenheit
FB foreign body
FBS fasting blood sugar
FDIU fetal death in utero
Fe Iron
FFP fresh frozen plasma
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Category Medical
Subject Abbreviations Page 5 of 13
FHT fetal heart tones
fib fibula
fl;fld fluid
ft. foot
FTA flourescent treponeal antibody
f/u follow-up
FUO fever of unknown origin
Fx fracture
g gram
G gravida
GA general anesthesia
GB gallbladder
GC; Gc Gonococcus, gonorrhea
GE gastroesophogeal
gen. general
GERD gastroesophogeal reflux disease
GGT gamma glutamyl transpeptidase
GI gastrointestinal
GM; gm gram
GP General Practitioner
gr. grain
GSW gun shot wound
Gt; gt drop
Gtt; gtt drops
GTT glucose tolerance test
GU genitourinary
Gyn Gynecology
H; h hour
HA headache
Hb. Hemoglobin
HCM health care maintenance
HCT hematocrit
HEENT head, eyes, ears, nose, and throat
Hemi hemiplegic
Hep A hepatitis A
Hep B hepatitis B
Hep C hepatitis C
Hg mercury
Hgb hemoglobin
HIV human immunodeficiency virus
H.O. House Officer
H/O history of
H&P history and physical
HR heart rate
hs at bedtime, hour of sleep
HTN hypertension
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Category Medical
Subject Abbreviations Page 6 of 13
Hx history
ICD intracardiac defibrillator
ICS intercostal space
ICU intensive care unit
I&D incision and drainage
I&D irrigation and drainage
i.e. that is
IGA immunoglobulin A
IGM immunoglobulin M
IHSS idiopathic hypertrophic subaortic stenosis
inf. inferior
IM intramuscular
IN inches
I&O intake and output
IOL intra-ocular lens
IOP intraocular pressure
IP interphalangeal
IQ intelligence quotient
IS intercostal space
ITN intrathecal narcotic
IUGR intrauterine growth retardation
IUP intrauterine pregnancy
IUPC intrauterine pressure catheter
IV intravenous
IVP intravenous pyelogram
JVP jugular venous pressure
K potassium
Kcal kilocalories
KCl potassium chloride
kg kilogram
KUB kidney, ureters, bladder
L lumbar
L&A light and accomodation
lab laboratory
Lac laceration
LAD left anterior descending
lap laparotomy/laparosocpy
lat lateral
LBW low birth weight
LCL lateral collateral ligament
LE lower extremity
Li Lithium
lig ligament
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 7 of 13
lb pound
LBP low back pain
liq liquid
LLL left lower lobe
LLQ left lower quadrant
LMP last menstrual period
LNMP last normal menstrual period
LOC level of consciousness
LP lumbar puncture
LS lumbosacral
LTC long term care
LUL left upper lobe
LUQ left upper quadrant
LVH left ventricular hypertrophy
M; m meter
MA mental age
MAT multifocal atrial tachycardia
MCA motorcycle accident
mcg microgram
MCL medial collateral ligament
MCP metacarpophalangeal
mEq milliequivalent
mg milligram
MI myocardial infarction
MICU medical intensive care unit
MI-CD mentally ill and chemically dependent
ml milliliter
mm millimeter
mmgm millimicrogram
mod. moderate
MR mentally retarded
MR mitral regurgitation
MRI magnetic resonance imaging
MS multiple sclerosis
MS morphine sulfate
MS/MI mitral valve stenosis/mitral valve insufficiency
MSPN Medical Student progress note
MTP metatarsophalanageal
MTX methotrexate
M/V motor vehicle
MVR mitral valve regurgitation
Na sodium
NB newborn
neg. negative
Neuro neurology
NG nasogastric
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 8 of 13
NH4 ammonium chloride
NKA no known allergies
NKDA no known drug allergies
no. number
noc. night
non rep do not repeat
NPH normopressure hydrocephalus
npo nothing by mouth
NSR normal sinus rhythm
NST non-stress test
NSVD normal spontaneous vaginal delivery
ntg. Nitroglycerin
NWB nonweight bearing
O2 oxygen
OB obstetrics
OBS organic brain syndrome
OCT oxytocin challenge test
OD right eye
OFC occipitofrontal circumference
OGTT oral glucose tolerance test
O.M. otitis media
omn..hoc. every hour
omn.noc. every night
OPD out patient department
Opthth ophthalmology
OPV oral polio vaccine
OR operating room
ORIF open reduction, internal fixation
Orth orthopedics
os by mouth
O.S. left eye
OT occupational therapy
oto otology
O.U. both eyes
oz. Ounce
p para
p after
p pulse
P-A posterior/anterior
P&A percussion and auscultation
PACU post anesthesia recovery room
PAT paroxysmal atrial tachycardia
Path pathology
pc after meals
PCA patient controlled analgesia
PCL posterior cruciate ligament
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 9 of 13
PD peritoneal dialysis
PDA patent ductus arteriosis
PE physical examination
Ped. Pediatrics
per by
PERRLA Pupils Equal Round React to Light and Accomodation
PH past history
PICU pediatric intensive care unit
PID pelvic inflammatory disease
PIH pregnancy inducted hypertension
PIP proximal interphalangeal
PKU phenylketonuria
PM&R physical medicine and rehabilitation
PMS prementrual syndrome
PND paroxysmal nocturnal dyspnea
P.O. by mouth
POD post operative day
pp post prandial
PP post partum
PPTL post partum tubal ligation
PPD post partum day
PRBCs packed red blood cells
pre-op pre-operative
prep preparation
PRIND partially reversed ischemic neurologic deficit
PRN as needed, as necessary
PROG prognosis
PROM passive range of motion
PROM premature rupture of membranes
Psy. Psychiatry
pt. Patient
PT physical therapy
PTA prior to admission
PTCA percutaneous transvenous coronary angioplasty
PTSD post traumatic stress disorder
ptt. partial thromboplastin time
PVCs premature ventricular contractions
PWB partial weight bearing
q every
qam every morning
qd every day
qh every hour
q 2h every 2 hours
qhs every night
qid four times a day
qns quantity not sufficient
qod every other day
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 10 of 13
qs quantity sufficient
qt. quart
Quad quadriplegie
R respiration
RBC red blood cell
RCA right coronary artery
RDS respiratory distress syndrome
Rehab rehabilitation
rep. let it be repeated
Rh rhesus
RLL right lower lobe
R/O rule out
ROM range of motion
RR respiratory rate
RUL right upper lobe
RUQ right upper quadrant
Rx treatment
s without
S sacral
SAB spontaneous abortion
SAH subarachnoid hemorrhage
SAO2 pulse oximetry O2 saturation
SBE subacute bacterial endocarditis
SBO small bowel obstruction
SBP systolic blood pressure
SCI spinal cord injury
SDH subdural hematoma
SDS same day surgery
SGOT serum glutamic oxalacetic transaminase
SGPT serum glutamic pyruvic transaminase
SGW shotgun wound
SI sacrolliac
SIADH syndrome of inappropriate anti diuretic hormone
SICU surgical intensive care unit
SIDS sudden infant death syndrome
SLE systemic lupus erthematosus
SLR straight leg raising
SO significant other
SOB short of breath
sol. Solution
S/P status post
spec. specimen
SPT serum pregnancy test
sp.gr. specific gravity
sq subcutaneous
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 11 of 13
S&R seclude and restrain
SROM spontaneous rupture of membranes
ss half
SSS sick sinus syndrome
Staph. Staphylococcus
stat at once, immediately
STD sexually transmitted disease
Strep. Streptococcus
STSG split thickness skin graft
sup. Superior
Surg surgery
sx symptoms
sym. Symptoms
syr. Syrup
T temperataure
T&A tonsillectomy and adenoidectomy
tab. Tablet
TAB threatened abortion
TACS trauma acute care surgery service
TAH total abdominal hysterectomy
TB; tb tuberculin
TBG thyroid binding globulin
TBI traumatic brain injury
TBSA total body surface area
TEE transesophogeal echocardiogram
temp. temperature
TF to follow
TIA transient ischemic attack
tid three times a day
tib tibia
TKA total knee arthroplasty
TM tympanic membrane
TORCH toxoplasmosis, rubella, cytomegalovirus, herpes simplex
TORCHS toxoplasmosis, rubell, cytomegalovirus, herpes simplex, syphilis
TPN total parenteral nutrition
TPR temperature, pulse, respiration
TR time request
Tx treatment
T-spine thoracic spine
TSH thyroid stimulating hormone
TTA trauma team activation
TTN transitory tachypnea of newborn
TUR transurethral resection
TURP transurethral resection of prostate
Type 1 DM insulin dependent diabetes mellitus
Type 2 DM non-insulin dependent diabetes mellitus
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 12 of 13
UA urinalysis
UC urine culture
UE upper extremity
ung. Ointment
UPJ ureteropelvic junction
URI upper respiratory infection
UPT urine pregnancy test
Urol. Urology
UTI urinary tract infection
vag. Vagina
VBAC vaginal birth after cesarean
VCUG voiding cytourethrogram
VD venereal disease
VHD valvular heart disease
vol.% volume percent
V/Q scan ventilation perfusion lung scan
VS vital signs
VSD ventriculoseptal defect
WBC, wbc white blood count
w/c wheelchair
WD well-developed
WN well-nourished
WNL within normal limits
WT, wt weight
w/v weight by volume
Y/O year old
WSCHS Clinical Manual
Category Medical
Subject Abbreviations Page 13 of 13
Symbol Definition:
Effective 1/00 Approval Medical Director_____________________________
Executive Director____________________________
c-abbrev
................
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