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-

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