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

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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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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

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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

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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

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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

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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

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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

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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

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Category Medical

Subject Abbreviations Page 13 of 13

Symbol Definition:

Effective 1/00 Approval Medical Director_____________________________

Executive Director____________________________

c-abbrev

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