ABBREVIATIONS nicians.org



CHERRY STREET HEALTH SERVICES

POLICY AND PROCEDURE

SUBJECT: Approved abbreviations and symbols

POLICY: Cherry Street Health Services will maintain a current list of approved abbreviations and symbols. To avoid confusion and possible errors, staff will limit the use of abbreviations and symbols used in patient care documentation to the approved list.

PROCEDURE:

1. A list of approved abbreviations and symbols will be developed and maintained by the Safety Committee (see Attachment A).

2. The list will be made available to staff during orientation and as additions/changes are made.

3. The list will be available online and posted in areas where documentation is likely to occur.

1/13/2006

ATTACHMENT A

APPROVED ABBREVIATIONS AND SYMBOLS

A

A assessment

A) axillary

ā before (ante)

AA Alcoholics Anonymous

Ab abortion

ac ante cebum (before meals)

AC joint acromioclavicular joint

AD right ear- listed unacceptable

ADA American Diabetic Association

ADD attention deficit disorder

ADHD attention deficit hyperactivity disorder

AIDS Acquired Immune Deficiency Syndrome

AKA above knee amputation

AMA against medical advice

Amt amount

AN anorexia nervosa

ANA antinuclear antibody test

AODM adult onset diabetes mellitus

AP anteroposterior

APOP Tylenol

Approx approximately

AROM active range of motion

AS left ear- listed unacceptable

ASA aspirin

ASAP as soon as possible

Assoc associated/association

ATC around the clock

AU both ears – listed unacceptable

AV arteriovenous

AVM arteriovenous malformation

AR aortic regurgitation

ARI acute renal insufficiency

AS aortic stenosis

B

BE, BaE barium enema

BBS bilateral breath sounds

BC bone conduction (Rinnes test)

BCCCP Breast and Cervical Cancer Control Program

BCP birth control pill

bid 2 times per day

bilat bilateral, bilaterally

BKA below knee amputation

BM bowel movement

BMI basal metobolic rate

BP blood pressure

BPD bronchopulmonary dysplasia

BPH benign prostatic hypertrophy

BRAT diet banana, rice cereal, applesauce and toast diet

BS bowel sounds

BSE breast self exam also see SBE –self breast exam

BSO bilateral salpingo-oophorectomy

BTL bilateral tubal ligation

BV bacterial vaginitis

Bx biopsy

C

c with (cum)

CA carcinoma

C1…C7 cervical vertebrae

Ca++ calcium

CAD coronary artery disease

CAT computed axial tomography

CBC complete blood count

cc cubic centimeter – on unacceptable list

*CC complex case

CCE clubbing, cyanosis or edema

CFS chronic fatigue syndrome

CHD congential heart disease

CHF congestive heart failure

Chol cholesterol

CIN cervical intraepithelial neoplasia

Circum circumference

Cl chloride

cm centimeter

CMT cervical motion tenderness

CNS central nervous system

CN II-XII cranial nerves 2-12

c/o complaint of

CO carbon monoxide

CO2 carbon dioxide

COPD chronic obstructive pulmonary disease

CP cerebral palsy

CPE complete physical exam

CPR cardiopulmonary resuscitation

C/S Cesarean section

CT scan computed tomography scan

CTA clear to auscultation

CV cardiovascular

CVA cerebral vascular accident

CXR chest X-Ray

D

diam diameter

DAW dispense as written

d/c or D/C discontinue – listed unacceptable

0 D/C no discharge

DID Dissociative Identity Disorder

DIP distal interphalangeal (joint)

dl deciliter

dm decimeter

DM diabetes mellitus

DM1 diabetes type 1

DM2 diabetes type 2

DNR Do Not Resuscitate

D.O. Dr of Osteopathy

DOE dyspnea on exertion

DSS Dept of Social Services

DT’s delirium tremers

DTR deep tendon reflexes

DUB dysfunctional uterine bleeding

DVT deep venous thrombosis

Dx diagnosis

E

E1 estrone

E2 estrogen (estradiol)

E3 esteriol

EaB elective abortion

EAC external auditory canal

EBV Epstein-Barr virus

EC enteric coated

ECHO echocardiogram

ED Emergency Department

EDC estimated date of confinement

EEG electroencephalogram

EGA estimated gestational age

EGD esophagastroduodenscopy

EKG Electrocardiogram

EMG electromyography

ESRD end stage renal disease

ENT ears, nose and throat

EOMI extra ocular movements intact

EPSDT early periodic screening and developmental testing

ER emergency room

ET endotracheal

ERCP endoscopic retrograde cholangiopancreatography

ETOH alcohol

F

FB foreign body

FBG fasting blood glucose

FBS fasting blood sugar

FDLMP first day of last menstrual period

Fe+ Iron

FH fundal height

FmHx family history

FROM full range of motion

FTI free thyroxin index

F/U follow up

Fx fracture

G

G gravida

GA gestational age

GC gonorrhea (gonococcus)

GERD gastroesophageal reflux disease

GG gamma globulin

GI gastrointestinal

GLUC glucose

gtt; gtts drop; drops

GTT glucose tolerance test

GU genitourinary

GYN gynecology

H

HA headache

HCG Human Chorionic Gonadotropin

Hct hematocrit

HCT Hydrocortisone

HD hemodialysis

HDL high-density lipoprotein

HEENT head, ears, eyes, nose and throat

Hgb hemoglobin

H&H hemoglobin and hematocrit

HI homicidal ideation

HIV human immunodeficiency virus

HJR hepato-juglar reflux

HMG-CoA 3-hydroxy-3methylglutaryl-coenzyme

HNP herniated nucleus pulposus

H/O history of

HOB head of bed

hosp hospital

H&P history and physical

HPV human papilloma virus

hr hour

HRT hormone replacement therapy

hs hour of sleep (bedtime)

HSM hepatosplenomegaly

HSV herpes simplex virus

HTN hypertension

H.V. Home visits

HVA homovanillic acid

hyst hysterectomy

Hx history

I

I independent

IBD inflammatory bowel disease

IBS irritable bowel syndrome

IBU Ibuprophen

incl. Including

ID identification

I&D incision and drainage

IDDM insulin dependent diabetes mellitus

i.e. that is

ILD interstitial lung disease

IM intramuscular

Imms Immunizations

inpt inpatient

IPV inactivated poliovirus vaccine

irreg irregular

IV intravenous

IVP intravenous pyelogram

J, K

JVD jugular venous distention

K+ potassium

KCHD Kent County Health Department

L

L left

L1-L5 lumbar vertebrae 1-5

lb pound

L&D labor and delivery

LE lower extremity

LLE left lower extremity

LLL left lower lobe (lung)

LLQ left lower quadrant

LMP last menstrual period

LNMP last normal menstrual period

LS lumbosacral

LS-spine lumbosacral spine

LSB left sternal border

LUE left upper extremity

LUQ left upper quadrant

M

MA medical assistant

mcg microgram

MCL midclavicular line

MCP metacarpophalangeal joint

M.D. Medical Doctor

MD Muscular dystrophy

MDI metered-dose inhaler

Med (s) medication, medications

mEq milliequivalent

MFM maternal fetal medicine

mg milligram

MI myocardial infarction

MMR measles, mumps and rubella

0 M/G/R no murmur/gallops/or rubs

MP metacarpophalangeal joint

MR mitral regurgitation

MRI Magnetic Resonance Imaging

MSS Maternal Support Services

MSW Master’s of Social Work

MTP metatarsophalangeal joint

MVA motor vehicle accident

MVP mitral valve prolapse

N

NAD no acute distress

NCT nerve conduction test

NC/AT normocephalic/atraumatic

Nd/NT, + BS non-distended/non-tender, + bowel sounds

N, N nitrogen

NCV nerve conduction velocity

neg negative

neuro neurologic

NG nasogastric

NIDDM non-insulin dependent diabetes mellitus

NKMA no known medical allergies

NS normal saline

NSAID nonsteroidal anti-inflammatory drug

NSR normal sinus rhythm

N/V nausea and vomiting

NVD normal vaginal delivery

O

O. objective

O) oral

O2 oxygen

Ob/gyn obstetrics/gynecology

OCP’s oral contraceptive pills

OCD Obsessive Compulsive disorder

OD right eye

OE otitis externa

OM otitis media

outpt outpatient

OPV oral polio vaccine

OS left eye

OTC over the counter

OU both eyes

oz ounce

P

P plan

p after

PA-C Physician Assistant –Certified

Pap smear papanicolaou smear

pc after meals

PCP primary care provider

PE physical exam

PEFR peak expiratory flow rate

PEG gastrostomy tube

PERRLA pupils are equal, round, reactive to light and accommodation

PHD Public Health Department

PHN Public Health Nurse

Phos phosphorus

PID pelvic inflammatory disease

PIP proximal interphalangeal joint

PMH past medical history

PN progress notes

PND paroxysmal nocturnal dyspnea

PNV Prenatal vitamins

po by mouth

pos positive

pp post prandial

PPB pap, pelvic and breast

ppd packs per day

PPD purified protein derivative (of TB)

PR per rectally

Preg pregnant

Prn as needed

PRO protein

Pro time prothrombin time

PSA prostate specific antigen

PSH past surgical history

pt patient

PT physical therapy

PTSD post traumatic stress disorder

PUD peptic ulcer disease

Pulmonary HTN pulmonary hypertension

PVD peripheral vascular disease

Q

q every

QD every day – on unacceptable list

qid four times per day

qod every other day – listed unacceptable

R

®; rt right

RA rheumatoid arthritis

RBC red blood cell

RBG random blood glucose

RBS random blood sugar

RCC Rape Crisis Center

RCM right costal margin

RD Registered Dietician

RDS respiratory distress syndrome

Re: regarding

resp respiratory

RF rheumatoid factor

RHD rheumatic heart disease

RI renal insufficiency

RLE right lower extremity

RLL right lower lobe (lung)

RLQ right lower quadrant

RN Registered Nurse

R/O rule out

ROM range of motion/ rupture of membranes

ROV return office visit

RRR regular rate and rhythm

RSB right sternal border

RSR regular sinus rhythm

RSV respiratory syncytial virus

RUE right upper extremity

RUQ right upper quadrant

Rx prescription

S

S subjective

s without

SAB spontaneous abortion

SBE self breast exam

Sch schedule (d)

S/E side effects

Sed rate sedimentation rate

SG Specific Gravity

SHx social history

Short ICP short intracontraceptual period

SI sacroiliac

S/I suicide ideation

SIL squamous intraepithelial lesion

SL sublingual

SLE systemic lupus erythematosus

SLR straight leg raise

SMAC sequential multiple analyzer – chemistries

SO significant other

SOB shortness of breath

SQ subcutaneous

S/P status post

S/Sx signs and symptoms

STAT immediately

STD sexually transmitted disease

SubQ subcutaneous – listed on unacceptable list use SQ

SVT supraventricular tachycardia

T

T1…T12 thoracic vertebrae 1-12

T3 triiodothyronine

T4 thyroxine

T7 free thyroxin factor

Tab tablet

TAB therapeutic abortion

TB tuberculosis

TD Tetanus-diptheria toxoid (child type)

Td Tetanus-diptheria toxoid (adult type)

tbsp tablespoon

temp temperature

TIBC total iron-binding capacity

Tib/fib tibia/fibula

tid three times per day

TM tympanic membrane

TMJ temporomandibular joint

TPR temperature, pulse and respiration

TR tricuspid regurgitation

TS tricuspid stenosis

TSH thyroid-stimulating hormone

tsp teaspoon

Type 1 DM Type one Diabetes Mellitus

Type 2 DM Type two Diabetes Mellitus

Tx treatment

U

UA urinalysis

UC urine Culture

UE upper extremity

UGI upper gastrointestinal

URI upper respiratory infection

U/S ultra sound

UTI urinary tract infection

V

VCUG voiding cystourethrogram

V-tach ventricular tachycardia

VN visiting nurse

VNA Visiting Nurse Association

vs versus

VS vital signs

VSS vital signs stable

W, X, Y and Z

w/u work up

WBC white blood cell

WCC well child check

WDWN well-developed, well nourished

WFL within functional limits

WIC Women Infants, hildren (program) testing

wk week

WNL within normal limits

0 W/R/R no wheezes/rales/rhonci

x times

x except

yr year

Zn zinc

HOSPITALS

S.H.D.C. Spectrum Downtown Health Campus

S.H.E.C. Spectrum East Campus

SH BMMC Spectrum Health Blodgett Campus

SMH Saint Mary’s Hospital

Metro Metropolitan

CSHS FACILITY NAME ABBREVIATIONS

BE Belknap

BHC Burton Health Center

BO Booth

CSHS Cherry Street Health Center

FAHC Ferguson Adult Health Center

FDHC Ferguson Dental Health Center

GRP Grand Rapids Pediatrics

H.I.S. Health Intervention Services

UHSHC Union High School Health Center

WSHC West Side Health Center

OPTICAL ABBREVIATIONS

AC Anterior Chamber

APD Apparent pupilary defect

ARMD Age related macular degeneration

AV Artery to vein ratio

CATS Cataract

CD Cup to disc ratio

DES Dry Eye Syndrome

Ep Esophoria

Et Esotropia

IOP Intraoccular Pressure

LEE Last Eye Exam

LLC Lens, lid, cornea

LLL Lower left lid

LRL Lower right lid

NPC Near point conversion

OAG Open Angle Glaucoma

OD Doctor of Optometry

OD Right Eye

OS Left Eye

OU Both Eyes

PD Pupilary Distance

PERRLA Pupil equal round reactive to light accommodation

RD Retinal detachment

SLE Slit lamp examination

ULL Upper left lid

URL Upper right lid

VA Visual Acuity

VF Visual Field

WNL Within normal limits

Xp Exophoria

Xt Exotropia

5/95 R 5/97

R5/99,R6/00

RX/04

Reviewed 1/06

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