TRI-COUNTY HEALTH CARE CONSORTIUM
TRI-COUNTY HEALTH CARE CONSORTIUM
Policy: Approved Abbreviations for Use in Medical Records
Policy Manual: Clinical
Approved: ______________________________Date: _______________________
Revised: _______________________________Date: ________________________
Policy:
To avoid misinterpretation, symbols and abbreviations are used in the medical record only when they have been approved by the Medical Staff (Providers) and when there is an explanatory legend available to those authorized to make entries in the medical record and to those who must interpret them.
Guidelines:
1. A copy of this policy will be maintained in each providers office, all patient care/nursing areas and each medical records file room.
2. Any proposed additions or deletions to the list will be directed to the medical director, to be taken to the providers for consideration.
OTC’S APPROVED SYMBOLS AND ABBREVIATIONS LISTING
SYMBOLS:
# Number
? question
% percent
& and
◦ Degree
+ positive
+/- positive or negative
< less than
➢ greater than
@ at
↓ Decreased
↑ Increased or elevated
♀ Female
♂ Male
- negative
ABBREVIATIONS
-A-
A.A. Alcoholics Anonymous
AAA Abdominal Aortic Aneurysm
ab abortion
abd abdomen
Abd Hyst abdominal hysterectomy
ABG arterial blood gases
ABI ankle brachial indices
abn abnormal
Abx antibiotics
AC acromioclavicular
a.c. before meals
Acid Phos acid phosphatase
ACL anterior cruciate ligament
ACLS advanced cardiac life support
ACOS American College of Surgeons
ACTH adrenocorticotrophic hormone
A.D.A. American Disability Act
ADA American Diabetic Association
ADDM adult onset diabetes mellitus
ad lib as desired
ADL activities of daily living
adm admission
adj adjustment
AFB acid fast bacillus
AHA American Heart Association
AICD Automatic Implantable Cardioverter Defibrillator
AK above knee
AKA above knee amputation
Alk phos Alkaline Phosphatase
a.m. before noon
A.M.A. American Medical Association
AMA against medical advice
amb ambulatory
AMD Advanced Medical Directive
AMI acute myocardial infarction
amp ampule
Amt amount
ANA Antinuclear antibody
ant anterior
ante before or pre
AP anteroposterior
AP & lat Anterior, posterior and Lateral
AP repair Anterior & Posterior repair
approx approximate
appt. appointment
ARDS Acute Respiratory Distress Syndrome
ARF acute renal failure
A.S. left ear
ASA aspirin
ASAP as soon as possible
As tol. As tolerated
ASCVD arteriosclerotic cardiovascular disease
ASD atrial septal defect
ASHD arteriosclerotic heart disease
Aso titer anti-streptolysis titre
Asst assistance
Atm atmosphere of pressure
A.U. both ears
AV aortic valve
AVF arteriovenous fistula
aVF augmented unipolar ECG leads
aVL augmented unipolar ECG leads
aVR augmented unipolar ECG leads
AVR Aortic Valve Repair/Replacement
-B-
BBB bundle branch block
BCC basal cell carcinoma
b.i.d. twice daily
Bilat bilaterally
Bili bilirubin
BIPAP Bi-Level Positive Airway pressure
BK below the knee
BKA below knee amputation
Bld blood
BM bowel movement
BMI Basal Metabolic index
BMR basal metabolic rate
BMT bilateral myringotomy tubes
BP blood pressure
BPH benign prostatic hypertrophy
BRP bathroom privileges
BS blood sugar
BSA Body surface area
BSO bilateral salpingo-oophoectomy
BTL bilateral tubal ligation
BUN blood urea nitrogen
Bx biopsy
-C-
c with
C1, C2 first cervical vertebra; second cervical vertebra, etc.
C&S culture and sensitivity
Ca calcium
CA carcinoma
CABG coronary artery bypass graft
CAD coronary artery disease
Cal calorie
Cap capsule
CAT Scan computerized axial tomography scan
Cath catheter (ize)
CBC complete blood count
CC chief comlaint
CCA Common Carotid Artery
CCU coronary care unit
CDC Centers for Disease Control
chemo chemotherapy
CHF congestive heart failure
Circ circumcision
Cl chloride
cm centimeter
CMN Childrens Miracle Network
CNS central nervous system
c/o complains of
CO2 carbon dioxide
Coag coagulation
COLO Colonoscopy
COPD chronic obstructive pulmonary disease
CP Cerebral Palsy
CPAP continuous positive airway pressure
CPD cephalopelvic disproportion
CPK creatine phosokinase
CPR cardiopulmonary resuscitation
CQI Continuous Quality Improvement
CRF chronic renal failure
C-section Cesarean section
CSF cerebrospinal fluid
CT chest tube
ct count
CT scan computerized axial tomography scan
CTA clear to auscultation
cult culture
CV cardiovascular
CVA cerebrovascular accident
CVD cardiovascular disease
CVP central venous pressure
Cx cervix
CXR chest xray
cysto cystoscopy
-D-
/d per day
d day, 24 hours
D & C dilatation and curettage
D & E dilation and evacuation
D-5-S dextrose (5%) in saline
D-5-W dextrose (5%) in water
D1, D2 , 1st dorsal (thoracic) vertebrae,, 2nd dorsal (thoracic vertebrae)
dB decibel
DDS Doctor of Dental Surgery
Demo demostrate
dept department
DES diethylstilbestrol
DFS Division of Family Services (MO)
DIC disseminated intravasular coagulation
diff differential blood count
Dig digoxin
DIP distal interphalangeal (joint)
DJD degeneraative joint disease
DKA Diabetic Ketoacidosis
D/L/R dextrose/lactated/ringers
DM diabetes mellitus
DME durable medical equipment
DNR do not resuscitate
DO Doctor of Osteopathy
DOA dead on arrival
DOB date of birth
DP Dorsalis Pedis
DPT diphtheria, pertusis, tetanus
dsg dressing
DT delirium tremens
DTR deep tendon reflex
DVT deep vein thrombosis
D/W dextrose in water
Dx diagnosis
-E-
EBL estimated blood loss
ECCE extracapsular cataract extraction
ECG electrocardiogram
E.coli Escherichia coli
ECT electroconvulsive therapy (electroshock)
Ed Education
ED Emergency Department
EDC expected date of confinement
EEA end-to-end anastomosis
EEG electroencephalograph
EENT ear, eye, nose and throat
EFM external fetal monitor
e.g. for example
EGD esophagogastroduodenoscopy
EKG electrocardiogram
emerg emergency
EMG electromyogram
EMS emergency medical services
ENT ears, nose and throat
EOM extraocular movement
Eosin eosinophils
ER emergency room
ERCP endoscopic retrograde cholangiopancreatogram
ESR erythrocyte sedimentation rate
ESRD end stage renal disease
Est. estimated
E-stim electrical stimulation
ESWL extracorporeal sound wave lithotripsy
et and
ET-Tube endotracheal tube
ETOH alcohol
EUA examination under anesthesia
eval evaluate: evaluation
exam examination; examined
exc excision
Exp. Lap exploratory laparotomy
-F-
5-FU 5-Flourouracil
F female
FACP Fellow of the American College of Physicians
FACS Fellow of the American College of Surgeons
FB foreign body
FBS fasting blood sugar
FDA Food and Drug Administration
Fe iron
FESS functional endoscopic sinus surgery
FEV1 Forced expiration volume in one second
FFP fresh frozen plasma
FH family history
FHR fetal heart rate
FHT fetal heart tone
fib fibrillation
fl fluid
fl. oz. fluid ounce
Flex flexion
flu influenza
fluoro fluoroscopy
FM fetal monitor
FOB foot of the bed
FOV field of vision
F.P. family physician
fract. fracture
frag. fragment
freq. frequent
FS frozen section
FSH follicle-stimulating hormone
FT feeding tube
ft. foot; feet
FTSG full thickness skin graft
F/U follow-up
func functional
FUO fever of unknown origin
Fx fracture
-G-
G gravida
G-tube gastrostomy tube
gal gallon
GB gallbladder
GC gonococcus; gonorrhea
Gen general
GERD gastroesophageal reflux disease
GGT gamma glutamic trasaminase
GI gastrointestinal
Glu. glucose
gm. gram
gr. Grain
grav gravid (pregnant)
GSW gunshot wound
GTT glucose tolerance test
gtt. drops
GU genitourinary
GYN gynecology
-H-
h hour
H20 water
H202 hydrogen peroxide
HC03 bicarbonate
H & H hemoglobin and hematocrit
H & P history and physical
H/A headache
HCG human chorionic gonadotropin
HCT hematocrit
HD hemodialysis
HDL high density lipoprotein
HEENT head, eyes, ears, nose, and throat
HF heart failure
Hg mercury
Hgb hemoglobin
H/H hemoglobin and hematocrit
HHS Department of Health and Human Services
HIV human immuno virus
HNP herniated nucleus pulposus
HOB head of bed
HOH hard of hearing
hosp. hospital
HPI history of present illness
HR heart rate
hr. hour
h.s. at bedtime
ht. height
HTN hypertension
HVD hypertensive vascular disease
Hx history
hyper above or high
hypo hypodermic injection; low
hyst hysterectomy
Hz hertz
-I-
I & D incision and drainage
I & O intake and output
I131 radioactive iodine
IABP intra-aortic balloon pump
IBS irritable bowel syndrome
ICP intracranial pressure
ICU intensive care unit
ID identification
IDDM insulin dependent diabetes mellitus
i.e. that is to say
Ig immunoglobulin
IM intramuscular
IMP: impression
in. inch
in situ confined to the site of origin
in utero within the uterus
info. Information
Ing inguinal
inj. Injury
INR International Normalized Ratio
Ins. insurance
int internal
IO intraocular
IOL intraocular lens
IOP intraocular pressure
IP intraperitoneal
IPPB intermittent positive pressure breathing
IQ intelligence quotient
ITP idiopathic thrombocytopenic purpura
IUD intrauterine device
IUP intrauterine pregnancy
IUPC intrauterine pressure catheter
IV intravenous (ly)
IVP intravenous pyelogram
IVPB intravenous piggy back
-J-
-K-
k 1000
K potassium
KCL potassium chloride
kg. kilogram
KUB kidney, ureter, and bladder
-L-
l liter
L1, L2, etc first lumbar vertebra, second lumbar vertebra, etc.
lab laboratory
LAD left anterior descending
LAO left anterior oblique
lat lateral
LAVH laparoscopic assisted vaginal hysterectomy
lb. pound
LBBB left bundle branch block
LDH lactate dehydrogenase
LDL low density lipoprotein
LE lower extremity
lg large
LH luteinizing hormone
Li lithium
lig. Ligament
liq. Liquid
LLL left lower lobe/lung
LLQ left lower quadrant
LMP last menstrual period
LOA leave of absence
LOC local
L.O.C. loss of consciousness
LOS length of stay
LP lumbar puncture
LPN licensed practical nurse
L-S lumbo-sacral
LSH lutein stimulating hormone
Lt. or l left
ltd limited
LTL laparoscopic tubal ligation
LUQ left upper quadrant
LV left ventricle
LVH left ventricular hypertrophy
lmphs lymphocytes
lytes electrolytes
-M-
M male
m. meter
MAR medication administration record
MAST trousers military antishock trousers
max maximum
mcg micrograms
MCHC mean corpuscular hemoglobin concentration
MCV mean corpuscular volume
MD medical doctor
Menomet menometrorrhagia
mets metastases
mEq milliequivalents
Mg magnesium
mg milligram
MgS04 magnesium sulfate
mgmt management
MI myocardial infarction
micro microscopic
min minute
ML midline
ml milliliter
MMK Marshall-Marchetti Krantz
MMPI Minnesota Multiphasic Personality Inventory
mod moderate
MOM milk of magnesia
mono monocytes
MP metacarpo-phalangeal (hand)
mph miles per hour
MRI magnetic resonance imaging
MRSA methacillin resistant staphylococcus aureus
MS multiple sclerosis
M.S. Master of Science
MVA motor vehicle accident
MVP mitral valve prolapse
MVR Mitral Valve Replacement/Repair
-N-
N20 nitrous oxide
N & V nausea and vomiting
N.A. Narcotics Anonymous
N/A not applicable
Na sodium
NaC1 sodium chloride
NB newborn
NBN newborn nursery
neg negative
Neuro neurology
NG nasogastric
NH nursing home
Nitro nitroglycerin
NKA no known allergies
NKDA no known drug allergies
NO nitrous oxide
noct night
norm normal
NOS not otherwise specified
NPH neutral protamine Hagedorn (Insulin)
NPO nothing by mouth
N/S normal saline
NSAIDS nonsteroid anti-inflammatory drugs
NSR normal sinus rhythm
NST nonstress test
NSY nursery
N/V nausea/vomiting
N/V/D nausea, vomiting and diarrhea
NWB non-weight bearing
-O-
O orally
02 oxygen
OB obstetrics
OB-Gy n obstetrics-gynecology
obs observe; observation
occ occasional
OCG oral cholecystogram
O.D. right eye
OD overdose
oint ointment
OM otitis media
OMT osteopathic manipulative therapy
OOB out of bed
O/P outpatient
OPC outpatient clinic
OPD outpatient department
O & P ova and parasites
OR operating room
ORIF open reduction with internal fixation
Ortho Orthopedics
os mouth
OS left eye
OSA Obstructive Sleep Apnea
OSHA Occupational Safety & Health Administration
OT occupational therapy (ist)
OU both eyes
oz ounce
-P-
p after
P Para
P.A. physician assistant
PA posterior anterior
PAC premature atrial contraction
Pap smear papanicolaou smear
PAR post anesthesia recovery
Para parous, parity
PAT paroxysmal atrial tachycardia
Path pathology
PBI protein bound iodine
p.c. after meals
PC02 partial pressure carbon dioxide
PCP Primary Care Physician
PD peritoneal dialysis
PDA patent ductus arteriosis
P. E. pulmonary embolus
PE physical examination
PEDS pediatrics
PEEP postive end-expiratory pressure
PEG Percutaneous Endoscopic Gastrostomy
PERLA pupils equal, react to light
PFT pulmonary function test
pg pregnant
pH hydrogen ion concentration
PH past history
PI present illness
PID pelvic inflammatory disease
PIT pitocin
PKU phenylketonuria
Plat. Platelets
p.m. afternoon or evening
PMH past medical history
PMI point of maximal impulse
PM&R physical medicine and rehabilitation
PMS premenstrual syndrome
po by mouth, orally
PO2 partial pressure oxygen
PO4 phosphate
polys polymorphonuclear leukocytes
pos positive
post-op post-operative
post posterior
pre-op preoperative
preg pregnancy
prep preparation
prev. previous
PRN when needed
procto proctoscope
protime prothrombin time
PSA Prostatic Specific Antigen
psych psychiatric; psychology
PT physical therapy
pt. patient
PTCA percutaneous transluminal coronary angioplasty
PTH parathyroid hormone
PTT partial thromboplastin time
PUD peptic ulcer disease
pulm pulmonary
PVC premature ventricular contractions
PVD peripheral vascular disease
PX physical examination
-Q-
q every
QA quality assurance
q.am every morning
q2h every two hours
q.h. every hour
qhs at bedtime
qid four times daily
QM quality management
QNS quantity not sufficient
q4h every 4 hours
QRS segment of electrocardiograph
qs quantity sufficient
qt. quart
quad quadraplegia; quadraplegic
-R-
Resp. respirations
RA rheumatoid arthritis
RAO right anterior oblique
RBBB right bundle branch block
RBC red blood count
RCA right coronary artery
RD registered dietitian
RDS respiratory distress syndrome
rec recommend; recommendation
Re-eval reeavaluation
reg regular
Rehab rehabilitation
REM rapid eye movement
resp respiration
Retic.Count reticulocyte count
RF rheumatoid factor
Rh rhesus (with reference to blood factors)
R/L ringers lactate
RLE right lower extremity
RLL right lower lobe
RLQ right lower quadrant
R/O rule out
RM room
RML right mediolateral
RN registered nurse
ROM range of movement
rpm revolutions per minute
RRR regular rate and rhythm
RSR regular sinus rhythm
RT rspiratory therapy
Rt. or ® right
RTC return to clinic
RTN return
RTO return to office
RUE right uper extremity
RUL right upper lobe
RUQ right upper quadrant
Rx prescription
Rxn Reaction
-S-
s without
S04 sulfate
S-A sino-atrial
S & O salpingo-oopherectomy
Sa02 oxygen saturation
sats saturation
SBO small bowel obstruction
sed sedimentation
sedrate erythrocyte sedimentation rate
segs segmented neutrophils (polymorphonuclear leucocytes)
SGOT serum glutamic oxaloacetic acid transaminase
SGPT serum glutamic pyruvic transaminase
SIADH syndrome of inappropriate antidiuretic hormone
Sibs siblings
sl sublingual
SLE systemic lupus erythematous
sm small
SNF skilled nursing facility
SNU skilled nursing unit
SOAP subjective; objective; assessment; plan
SOB shortness of breath
soc hx social history
Sol. Solution
SOP standard operating procedure
S/P status post
Sp.gr. specific gravity
Spont. Spontaneous
SR sinus rhythm
S/S signs and symptoms
STD sexually transmitted disease
Staph staphylococcus
Stat at once, immediately
STO short-term observation
Strep streptococcus
STSG split thickness skin graft
Subq. Subcutaneous
Surg surgical; surgery
SVC superior vena cava
Sx symptoms
-T-
T temperature
T & A tonsil(ectomy) and adenoid (ectomy)
T & C type and crossmatch
T & S type and screen
T3 triiodothronine
T4 thyroxine
Tab tablet
TAH total abdominal hysterectomy
TB tuberculosis
tbsp tablespoon
TEE transesophageal echocardiogram
temp. temperature
TENS transcutaneous electrical nerve stimulation
TIA transient ischemic atttack
TIBC total iron binding capacity
t.i.d. three times daily
TLC total lung capacity
TM tympanic membrane
TNTC too numerous to count
TO Telephone order
tol tolerated
TPN total parenteral nutrition
TPR temperature, pulse and respiration
trach. Tracheostomy
TSH thyroid stimulating hormone
tsp. teaspoon
TURP transurethral resection of prostate
TV tidal volume
TVH total vaginal hysterectomy
tx treatment
-U-
UA urinalysis
UCG urine chorionic gonadropin (pregnancy test)
UC&S urine culture and sensitivity
UE upper extremity
UGI upper gastrointestinal
unilat unilateral
URI upper respiratory infection
Urol urology
UTI urinary tract infection
UV ultra-violet
-V-
V volume
vag. vaginal
Vanco Vancomycin
VBAC vaginal birth after cesarean section
VC vena cava
VD veneral disease
VDRL veneral disease research laboratory (syphillis serology test)
vent ventilator
V-fib ventricular fibrillation
via by way of
vit. Vitamin
VLDL very low density lipoprotein
VO verbal order
voc vocational
vol. volume
VRE Vancomycin Resistant Enterococcus
VS vital signs
vs. versus
VSD ventricular septal defect
V-tach ventricular tachycardia
VTX vertex
-W-
w/ with
WB whole blood
WBC white blood cell (count)
w/c wheelchair
W/F white female
WIC Women, Infants, Children Nutrition Program
W/M white male
WNL within normal limits
W/O without
wt. weight
-X-
X sign of multiplication
X-ray roentgen rays
X’s times
XX normal female chromosome type
XY normal male chromosome type
-Y-
yd yard
y/o years old
yr year
-Z-
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- ancient health care methods
- united health care premium payment
- nevada bureau of health care compliance
- argumentative health care topics
- health care persuasive speech topics
- adventist health care system jobs
- home health care jobs hiring
- home health care jobs near me
- bergen county health care center
- tri county polk county
- adventist health care urgent care rockville
- advent health home health care orlando