Hom
me Health and H
Hospice Care, In
nc. 14.10
0 ACCEP
PTABLE ABB
BREVIATIONS AND ACRO
ONYMS FOR
R CHARTING PURP
POSE: To
o provide a sstandardized
d method of uniform doccumentation
n in the he
ealth information record
d to promotee effective communicatiion throughout th
he agency an
nd for other healthcare p
providers. CEDURE: PROC
Note: Many of tthe attached
d abbreviatiions are nott appropriatee for use in the electronicc record. Staff should n
not use symb
bolic abbrevviations (ex., parentheses (), semi‐‐colon ; or quotes “ ”) in
n Horizon Ho
omeCare EH
HR. er informatio
on is placed w
within the reecord and a symbol or aabbreviation 1. Wheneve
is utilized, staff must use only tho
ose abbreviaations and syymbols that have been identified
d as accepted
d standards. Effective Date: July 1994 Revie
ew Date: July 1999, August 2001, March 20003, September 2005, Deecember e 2010 2006, June
Revission Date: July 1995, June 1996, June 1997, JJuly 1998, Seeptember 19
999, Septembe
er 2000, July 2004, Februuary 2007, A
April 2007, Ju
une 2007, Decemberr 2008, Septe
ember 20111, June 2012
Revie
ewed By: Kathryn A
Albritton, RH
HIA; Directorr of Professional Supporrt Services
Cindy Paylor PT, Rehaab Director
Approved by: VP
P of Clinical SServices
Date Page 1
1 of 21 14.10 Page 2 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING 3HC ACCEPTABLE INITIALS, ABBREVIATIONS, AND SYMBOLS FOR CHARTING 30 SEC STS 30 SECOND SIT TO STAND TEST 3HC 6MWD 6MWT A.D. a/o A/SE A/T ABC SCALE abd ABD ABG AD ADA ADD ADL adm admin AFB AFO AFP AIDS AIMS Home Health and Hospice Care, Inc. 6 MINUTE WALK DISTANCE 6 MINUTE WALK TEST auris dextra (right ear) as ordered actions and side effects assess and teach ACTIVITY‐SPECIFIC BALANCE CONFIDENCE SCALE abdomen, ABDUCTION (PT) arterial blood gas assistive device American Diabetic Association ADDUCTION activities of daily living admitted administered acid‐fast bacillus ankle foot orthosis Alphafetoprotein Acquired Immunodeficiency Syndrome abnormal involuntary movements AKA ALS AM AMA amb AML amt ant AP above‐the‐knee (amputation) Amyotrophic Lateral Sclerosis; morning against medical advice ambulate Acute Myelocytic Leukemia amount anterior apical pulse Page 2 of 21 14.10 Page 3 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING AP approx appt APS AROM ankle pumps (PT) approximately appointment Adult Protective Services active range of motion ASA ASCVD ASD ASHD asst aud aspirin arteriosclerotic cardiovascular disease arterial septal defect atherosclerotic heart disease assistance auditory ausc AV ax B&B B/T BBS BBT BCBS BCP BDF BE BGM bid bili BJH BKA bld BLE BM BMR BP BPH BR BRP auscultation atrioventricular axillary bowel and bladder between bilateral breath sounds basal body temperature Blue Cross/Blue Shield birth control pills bilateral dorsi‐flexion barium enema blood glucose monitor twice a day bilirubin Betsy Johnson Hospital below‐the‐knee (amputation) blood both lower extremities bowel movement basal metabolic rate blood pressure benign prostatic hypertrophy bedrest bathroom privileges Page 3 of 21 14.10 Page 4 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING BS BSC BSN BSW BTL BUE BUN BX C C&S C.C. c/o bowel sounds, breath sounds, blood sugar bedside commode Bachelor of Science in Nursing Bachelor of Social Work bilateral tubal ligation bilateral upper extremities blood urea nitrogen biopsy Centigrade, Celsius culture and sensitivity chief complaint complain of C1, C2, C3, etc. CA Ca CABG cap CAP/C CAP/DA CAP/MR CATH CBC CBG CBS CCU CD CDC CF CG CGA CHD CHEM 12 CHEM 7 chemo CHF first cervical vertebra, second cervical, etc. cancer, carcinoma calcium, cancer Coronary artery bypass graft capsule, capillary Community Alternatives Program for Children Community Alternatives Program for Disabled Adults Community Alternatives Program for the Mentally Retarded catheter, catheterize complete blood count capillary blood glucose chronic brain syndrome Coronary Care Unit Clinical Director Center for Disease Control, Child Development Center cystic fibrosis caregiver contact guard assist coronary heart disease sequential multiple analysis of 12 chemistry constituents sequential multiple analyzer with compound chemotherapy congestive heart failure Page 4 of 21 14.10 Page 5 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING chr CK Cl CLOF cm chronic check chloride current level of function centimeter CM CMM CMS CMV CNA CNS Case Manager Clinical Management Meeting Center for Medicare and Medicaid Services cytomegalovirus certified nursing assistant central nervous system Co CO2 comp. cont conv. coord. COPD COTA/L CP CP CPAP CPM CPR creat crit C‐sect CSF CT or CT scan CVA CVD CXR cysto D D&C county carbon dioxide comprehension continue conversation coordination chronic obstructive pulmonary disease Certified Occupational Therapy Assistant/Licensed cardiopulmonary cerebral palsy Continuous positive airway pressure Continuous passive motion cardiopulmonary resuscitation creatinine hematocrit Cesarean section cerebrospinal fluid computerized axial tomography scan cerebrovascular accident cardiovascular disease chest x‐ray cystoscopy dependent dilatation and curettage Page 5 of 21 14.10 Page 6 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING D&E D/C D/T D5W DAUG DEC Decub. DEMO DEMOS dept DF DGI: dilatation and evacuation discharge, discontinue due to 5% dextrose in water daughter Developmental Evaluation Clinic decubitus demonstrate demonstrations department dorsiflexion DYNAMIC GAIT INDEX TEST diff DJD DM DME DNR DO DOA DOB doc DOE DPT Dr. DRG DSD dsg DSS DTR dtr (lowercase) DTs DVT dx dz E. coli differential degenerative joint disease diabetes mellitus durable medical equipment do not resuscitate Doctor of Osteopathy dead on arrival date of birth document dyspnea on exertion diphtheria, pertussis, tetanus doctor diagnostic‐related‐group dry sterile dressing dressing Department of Social Services deep tendon reflex daughter delirium tremens deep venous thrombosis diagnosis disease Escheria Coli Page 6 of 21 14.10 Page 7 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING e.g. E/SE ea ECG, EKG ED for example effect and side effects each electrocardiogram emergency department EDU EEG EENT ELIM elix EMER education electroencephalogram eye, ear, nose and throat elimination elixir emergency EMS ENG ENT ENVIR EOB EOM eos EP EQUIPM ER ER esp ESRD et etc. etiol ETOH eval EX’S EXAC exam exp expir explap emergency medical services English ear, nose and throat environment edge of bed extraocular movement eosinophil epidural equipment emergency room external rotation (PT) especially end‐stage renal disease and and so on etiology ethyl alcohol evaluation exercises exacerbations examination expressive expiration, expiratory exploratory laparotomy Page 7 of 21 14.10 Page 8 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING Ext ext./EXT F F/U FBS FC FDA Fe FFST: FHR FHT FICSIT fl. oz fld Flex FMLA FNP FOB Freq. FSBS ft FUO FWB Fx., fract. gal GDAU extension external Fahrenheit follow‐up fasting blood sugar Foley catheter Food and Drug Administration iron FIVE TIME SIT TO STAND TEST fetal heart rate fetal heart tones Fraility And Injuries: Cooperative Studies Of Intervention Techniques (Tests Of Progressive Static Balance) fluid ounce fluid Flexion Family Medical Leave Act Family Nurse Practitioner foot of bed frequency finger stick blood sugar foot, feet fever of unknown origin full weight bearing fracture gallon granddaughter GI Gm, gm GT GT/TR GTT G‐Tube/GT GU gyn gastrointestinal gram gait training gait training glucose tolerance test gastrostomy tube genitourinary gynecology Page 8 of 21 14.10 Page 9 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING H&H H&P H/O H2O hemoglobin and hematocrit history and physical history of water H2O2 HA HB, Hgb HBs Ag HCG HCl HCT HCTZ hydrogen peroxide headache hemoglobin Hepatitis B surface antigen human chorionic gonadotrophin hydrochloric acid hematocrit hydrochlorithiazide HCVD HEENT HEP Hg HHA HHA HHN HI HIV HMO HOB HOH HOH Hosp/HOSP HR/R HS HS ht HT HTN Hwy hx HYDRA hypertensive cardiovascular disease Head, eyes, ears, nose and throat home exercise program mercury Home Health Aide, Home Health Agency Hand held assistance (PT) Home Health Nurse hearing impaired human immunodeficiency virus Health Maintenance Organization head of bed hard of hearing hand on hand (rehab) hospital heart rate and rhythm heel slide ham set (rehab) height heel taps hypertension highway history hydration Page 9 of 21 14.10 Page 10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING hyper hypo I I&D I&O above below independently, independent incision and drainage intake and output i.e. IADL ICF ICP ICU ID that is independent activities of daily living intermediate care facility intracranial pressure Intensive Care Unit identification/identify IDDM IDG IM in INC IND inf. inhal. INJ INR Ins. inspir instill. Instr. INT INT/EXT INTERACTS INTERVENT IOP IPPB IQ IR irr., irreg. ITC insulin dependent diabetes mellitus Interdisciplinary Group intramuscular inch increase independent infusion inhalation injection international ratio insurance inspiration, inspiratory instillation instruction internal internal/external interactions interventions intraocular pressure intermittent positive pressure breathing Intelligence quotient internal rotation irregular Interdisciplinary Team Conference Page 10 of 21 14.10 Page 11 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING IUD IUGR IV IVF IVP IVT JMH JVD K+ KAHC kg L/S/T intrauterine device intrauterine growth retardation intravenous intravenous fluid IV push intravenous therapy Johnston Memorial Hospital jugular venous distention potassium Kitty Askins Hospice Center kilogram lying, sitting, standing LA lab lang. lap LAQ lat lb. LBM LBP LBQC LD LE Lg/LGE liq LLB LLE LLL LLQ LMH LMP LOB LOC LP left atrium laboratory language laparotomy long arc quad lateral Pound loose bowel movement low back pain large based quad cane learning disability lower extremity large liquid long leg brace left lower extremity left lower lobe left lower quadrant Lenoir Memorial Hospital last menstrual period loss of balance level of consciousness, loss of consciousness, laxative of choice lumbar puncture Page 11 of 21 14.10 Page 12 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING LPN LPT LR LRAD LUE Licensed Practical Nurse Licensed Physical Therapist lactated Ringer's least restrictive assistive device left upper extremity LUL LUQ LVH lymph lytes m left upper lobe left upper quadrant left ventricular hypertrophy lymphocytes electrolytes meter max MCD mcg MCH McK MCL MCRA MCV MD Meas. Meds mEq Mg mg. mgm MGMT MI MIN min ml mm MMT MOD BORG, BORG mod/MOD MOM maximum Medicaid microgram mean corpuscular hemoglobin McKesson midclavicular Medicare mean corpuscular volume medical doctor measure medications milliequivalent magnesium milligram management myocardial infarction minimal minimum, minute milliliter millimeter manual muscle test scale to show rate of perceived exertion moderate milk of magnesia Page 12 of 21 14.10 Page 13 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING mono MR MRSA MS MSDS MSS MSSP MSW MVA MVI MVMT MVP monocytes, mononucleosis mentally retarded/medical record Methacillin Resistant Staph Aureus multiple sclerosis material safety data sheet Medical Social Services Master of Science, Speech Pathology Master of Social Work motor vehicle accident multivitamin movement Mitral Valve Prolapse N&V N/A N/S Na NA NaCL neg neuro NG NGT NH3 NHP NIDDM NKA No. noc NOC norm. NPI NPO NPU nsg. NSR nausea and vomiting not applicable or not addressed normal saline sodium Nursing Assistant Sodium Chloride negative neurology nasogastric nasogastric tube ammonia nursing home placment noninsulin dependent diabetes mellitus no known allergies number night, at night Nurse On‐Call normal National Provider Identification Number nothing by mouth not picked up nursing normal sinus rhythm Page 13 of 21 14.10 Page 14 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING NTG NWB O2 O2 sats OA nitroglycerin non weight bearing oxygen Oxygen saturation Osteoarthritis OASIS OB obj OBS occ OD Outcome Assessment and Information Set obstetrics object organic brain syndrome occasional overdose oint OJ OOB OOP OP Opth OR Ortho; Orth OSHA OSTEO OT OTC OTR/L OX Ox3 oz. P PA PAC PAP PARA Pb PBI PC ointment orange juice out of bed out of pocket ophthalmic ophthalmology operating room/by mouth/oral orthopedic Occupational Safety and Health Administration Osteoarthropathies Occupational Therapy over the counter Occupational Therapist, Registered/Licensed oximeter oriented to person, place, time ounce pulse physician's assistant Port‐a‐Cath Papanicolaou [test]; peak airway pressure paralyzed lead protein bound iodine personal care Page 14 of 21 14.10 Page 15 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING PCA PCMH pCO2 PDA PDR PE peds PEEP PEG per PERF PERLA personal care aide Pitt County Memorial Hospital partial pressure of carbon dioxide patent ductus arteriosus Physician's Desk Reference physical examination, pulmonary embolism pediatrics positive end‐expiratory pressure Percutaneous Endoscopic Gastrostomy by, through perform pupils, equal and reactive to light and accommodation PERRLA PF pH PICC PID PLOF/plof PM PMH PMM po/PO POA POC polys poplit pos post postop POT potent. PP PPD preop prep pupils, equal, round, reactive to light and accommodation plantarflexion hydrogen concentration peripherally inserted central catheter pelvic inflammatory disease prior level of function afternoon past medical history Professional Management Meeting by mouth power of attorney Plan of Care polymorphonuclear leukocytes popliteal positive posterior, postvocalic (after vowel) postoperative plan of treatment potential postprandial purified protein derivative preoperative preparation, prepare for Page 15 of 21 14.10 Page 16 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING PRES PRN PRNT PROB PROF present whenever necessary, as needed parent problem professional PROM protime pt PT PT/CG PTA passive range of motion prothrombin time patient physical therapy/prothrombin time patient/caregiver physical therapy assistant PTT PV PVC PVD PVR PWB q q am q2h, q3h, etc. QA QC qid QS R, rt. (R) R/O R/T RA RBC RBS rd re recep REM REPS partial thromboplastin time peripheral vascular premature ventricular contraction peripheral vascular disease post void residual partial weight bearing every every morning every two hours, every three hours, etc. quality assurance quad cane four times a day quad set right rule out reference to, related to rheumatoid arthritis, right atrium red blood cell, red blood count random blood sugar road regarding receptive rapid eye movement repetitions Page 16 of 21 14.10 Page 17 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING REQ MIN A resp Rh RH RHIA RHIT RLE RLL RLQ RML RN RNOC requires minimal assistance respiration, respiratory Rhesus factor right hand Registered Health Information Administrator Registered Health Information Technician right lower extremity right lower lobe right lower quadrant right middle lobe Registered Nurse RN On‐Call RNS ROM RSC RT RTC RTO RUE RUL RUQ RVH RW Rx S s/p S/S, S&S S/SE SA node SaO2 SAQ SASH SBA SBA SE request no service range of motion right subclavian respiratory therapist, therapy return to clinic return to office right upper extremity right upper lobe right upper quadrant right ventricular hypertrophy rolling walker therapy, treatment, prescription sitting status/post signs and symptoms symptoms/side effects sinus‐atrial node oxygen saturation in arterial blood short arc quads Saline Administration Saline Heparin stand by assistance standby assist side effects Page 17 of 21 14.10 Page 18 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING SEC sed rate SGOT SGPT SLB secondary sedimentation rate serum glutamic oxaloacetic transaminase serum glutamic pyruvic transaminase short leg brace SLP SLR SMA12 SMAC SN SNF Speech Language Pathologist straight leg raise sequential multiple analysis of 12 chemistry constituents sequential multiple analyzer with compound skilled nursing Skilled Nursing Facility SNV SO4 SOB SOC SP SPA SPC spec. spon., spont SPOU SPT SRMC SS SSE ST, SP Tx STAT stim SUBQ Sup SV SVC SW SWAL Sx, sympt Skilled Nursing Visit sulfate shortness of breath start of care date Speech Pathologist Spanish single point cane specimen spontaneous spouse stand/pivot/transfer Sampson Regional Medical Center Social Security soap suds enema speech therapy at once stimulation subcutaneous Supervision, supervisory supervisory visit superior vena cava Social Worker swallowing symptoms Page 18 of 21 14.10 Page 19 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING Syl. T&A T, temp T.O. t/f T/F SPT tab TB TBI Tbsp TC&DB TD syllables tonsillectomy and adenoidectomy temperature telephone order transfer transfer (stand, pivot, transfer) tablet tuberculosis traumatic brain injury tablespoon turn, cough and deep breathe transdermal TDWB Tech. Ther act Ther ex THR TIA tid, t.i.d. TKR tol. TPR trach TSA TSH TSM Dressing tsp TT TTB TTWB TUR TURP TV Tx UA touch down weight bearing technique Therapeutic activities therapeutic exercises total hip replacement transient ischemic attack three times a day total knee replacement tolerates temperature, pulse and respirations tracheostomy total shoulder arthroplasty thyroid stimulating hormone Transparent Semipermeable Membrane teaspoon transfer training tub transfer bench toe touch weight bearing transurethral resection transurethral resection prostate; Transurethal Prostectomy tidal volume treatment urinalysis Page 19 of 21 14.10 Page 20 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING UB UE UGI UKO umb upper body upper extremities upper gastrointestinal unknown origin umbilicus, umbilical UNC UR URI UTI VA VAD University of North Carolina Chapel Hill Utilization Review upper respiratory infection urinary tract infection Veteran's Administration/vaginal vascular access device vag VC/S AD VCS VD Vent via vit VO vol VP VS w/c w/d w/o w/p, WP WBAT WBC WC WFL WilMed wk WMC WMH WND vaginal verbal cues without assistive device verbal cues venereal disease ventilator by way of vitamin verbal order volume venipuncture vital signs wheelchair warm and dry without whirlpool weight bearing as tolerated white blood cells, white blood count wound care within functional limits Wilson Memorial Hospital week Wake Medical Center Wayne Memorial Hospital wound Page 20 of 21 14.10 Page 21 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING WNL wt. x yr    @ ~ 2 ° ‐ + = Δ > < ♂ within normal limits weight times year increase increased decreased at approximate secondary to degree minus, negative plus, positive equal to change greater than less than male female ♀ # ÷ % & c p number, pounds divided by percent and with after s without Page 21 of 21