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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