Acceptable Abbreviations/Acronyms for Charting
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Home Health and Hospice Care, Inc. 14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING PURPOSE: To provide a standardized method of uniform documentation in the health record to promote effective communication throughout the agency and for other healthcare providers. PROCEDURE: Note: Many of the attached abbreviations are not appropriate for use in the electronic record. Staff should not use symbolic abbreviations (ex., parentheses (), semi-colon ; or quotes “ ”) in Horizon HomeCare EHR. 1. Whenever information is placed within the record and a symbol or abbreviation is utilized, staff must use only those abbreviations and symbols that have been approved as accepted. Effective Date: Review Date: Revision Date: Reviewed By: July 1994 July 1999, August 2001, March 2003, September 2005, December 2006, June 2010 July 1995, June 1996, June 1997, July 1998, September 1999, September 2000, July 2004, February 2007, April 2007, June 2007, December 2008, September 2011, June 2012, October 2012, December 2013 Kathryn Albritton, RHIA; Director of Professional Support Services Meta Michelle Weeks, Nurse Mentor/PI Analyst; Sandra Pate RN BSN CRNI®, Education Manager Approved by: VP of Clinical Services Page 1 of 21 Date 14.10 Page 2 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING 3HC ACCEPTABLE INITIALS, ABBREVIATIONS, AND SYMBOLS FOR CHARTING Unapproved Abbreviations 1. qd 2. cc 3. MS 4. MSO 5. u 6. IU 7. MgSO 8. QOD 9. X.0 mg 10. .X mg 11. A.U. 12. µg Accepted Changes daily ml morphine morphine unit international unit magnesium every other day Xmg 0.Xmg both ears mcg 30 SEC STS 30 SECOND SIT TO STAND TEST 3HC 6MWD 6MWT A/O Home Health and Hospice Care, Inc. 6 MINUTE WALK DISTANCE 6 MINUTE WALK TEST Alert and oriented A/SE A/T ABC SCALE ABD ABD ABG AD ADA ADD actions and side effects assess and teach ACTIVITY-SPECIFIC BALANCE CONFIDENCE SCALE abdomen, ABDUCTION (PT) arterial blood gas assistive device American Diabetic Association ADDUCTION ADL adm admin AFB AFO AFP AIDS activities of daily living admitted administered acid-fast bacillus ankle foot orthosis Alphafetoprotein Acquired Immunodeficiency Syndrome Page 2 of 21 14.10 Page 3 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING AIMS AKA ALS AM AMA amb AML amt ant abnormal involuntary movements above-the-knee (amputation) Amyotrophic Lateral Sclerosis; morning against medical advice ambulate Acute Myelocytic Leukemia amount anterior AP AP apical pulse ankle pumps (PT) approx appt APS AROM ASA ASCVD ASD ASHD approximately appointment Adult Protective Services active range of motion aspirin arteriosclerotic cardiovascular disease arterial septal defect atherosclerotic heart disease asst aud ausc AV ax B&B B/T BBS BBT assistance auditory auscultation atrioventricular axillary bowel and bladder between bilateral breath sounds basal body temperature BCBS BCP BDF BE BGM bili BJH Blue Cross/Blue Shield birth control pills bilateral dorsi-flexion barium enema blood glucose monitor bilirubin Betsy Johnson Hospital Page 3 of 21 14.10 Page 4 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING BKA bld BLE BM BMR BP BPH BR BRP below-the-knee (amputation) blood both lower extremities bowel movement basal metabolic rate blood pressure benign prostatic hypertrophy bedrest bathroom privileges BS BSC bowel sounds, breath sounds, blood sugar bedside commode BSN BSW BTL BUE BUN BX C C&S Bachelor of Science in Nursing Bachelor of Social Work bilateral tubal ligation bilateral upper extremities blood urea nitrogen biopsy Centigrade, Celsius culture and sensitivity C.C. c/o C1, C2, C3, etc. CA Ca CABG CAP/C CAP/DA CAP/MR chief complaint complain of first cervical vertebra, second cervical, etc. cancer, carcinoma calcium, cancer Coronary artery bypass graft Community Alternatives Program for Children Community Alternatives Program for Disabled Adults Community Alternatives Program for the Mentally Retarded CATH CBC CBG CBS CCU CD CDC catheter, catheterize complete blood count capillary blood glucose chronic brain syndrome Coronary Care Unit Clinical Director Center for Disease Control, Child Development Center Page 4 of 21 14.10 Page 5 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING CF CG CGA CHD CHEM 12 CHEM 7 chemo CHF chr 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 chronic CK Cl check chloride CLOF cm CM CMS CMV CNS CO2 comp. current level of function centimeter Case Manager Center for Medicare and Medicaid Services cytomegalovirus central nervous system carbon dioxide comprehension cont conv. coord. COPD COTA/L CP CP CPAP CPM continue conversation coordination chronic obstructive pulmonary disease Certified Occupational Therapy Assistant/Licensed cardiopulmonary cerebral palsy Continuous positive airway pressure Continuous passive motion CPR creat C-sect CSF CT or CT scan CVA CVD cardiopulmonary resuscitation creatinine Cesarean section cerebrospinal fluid computerized axial tomography scan cerebrovascular accident cardiovascular disease Page 5 of 21 14.10 Page 6 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING CXR cysto D D&C D&E D/C D/T D5W DAUG chest x-ray cystoscopy dependent dilatation and curettage dilatation and evacuation discharge, discontinue due to 5% dextrose in water daughter DEC DEMO Developmental Evaluation Clinic demonstrate DEMOS DF DGI: diff DJD DM DME DNR demonstrations dorsiflexion DYNAMIC GAIT INDEX TEST differential degenerative joint disease diabetes mellitus durable medical equipment do not resuscitate DO DOA DOB doc DOE DPT Dr. DRG DSD Doctor of Osteopathy dead on arrival date of birth document dyspnea on exertion diphtheria, pertussis, tetanus doctor diagnostic-related-group dry sterile dressing dsg DSS DTR dtr (lowercase) DTs DVT dx dressing Department of Social Services deep tendon reflex daughter delirium tremens deep venous thrombosis diagnosis Page 6 of 21 14.10 Page 7 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING dz E. coli e.g. E/SE ea ECG, EKG ED EDU EEG disease Escheria Coli for example effect and side effects each electrocardiogram emergency department education electroencephalogram EENT ELIM eye, ear, nose and throat elimination elix EMER EMS ENG ENT ENVIR EOB EOM elixir emergency emergency medical services English ear, nose and throat environment edge of bed extraocular movement eos EP EQUIPM ER ER esp ESRD et etc. eosinophil epidural equipment emergency room external rotation (PT) especially end-stage renal disease and and so on etiol ETOH ETS eval EX’S EXAC exam etiology ethyl alcohol Endo Tracheal Suction evaluation exercises exacerbations examination Page 7 of 21 14.10 Page 8 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING exp expir explap Ext ext./EXT F F/U FBS FC expressive expiration, expiratory exploratory laparotomy extension external Fahrenheit follow-up fasting blood sugar Foley catheter FDA Fe Food and Drug Administration iron FFST: FHR FHT FICSIT fl. oz fld Flex 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 FMLA FNP FOB Freq. FSBS ft FUO FWB Fx., fract. 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 gal GDAU GI Gm, gm GT GT/TR GTT gallon granddaughter gastrointestinal gram gait gait training glucose tolerance test Page 8 of 21 14.10 Page 9 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING G-Tube/GT GU gyn H&H H&P H/O H2O H2O2 HA gastrostomy tube genitourinary gynecology hemoglobin and hematocrit history and physical history of water hydrogen peroxide headache HB, Hgb HBs Ag hemoglobin Hepatitis B surface antigen HCG HCl HCT HCTZ HCVD HEENT HEP Hg human chorionic gonadotrophin hydrochloric acid hematocrit hydrochlorithiazide hypertensive cardiovascular disease Head, eyes, ears, nose and throat home exercise program mercury HHA HHA HHN HI HIV HMO HOB HOH HOH 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) Hosp/HOSP HR/R HS HS ht HT HTN hospital heart rate and rhythm heel slide ham set (rehab) height heel taps hypertension Page 9 of 21 14.10 Page 10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING Hwy hx HYDRA hyper hypo I I&D I&O i.e. highway history hydration above below independently, independent incision and drainage intake and output that is IADL ICF independent activities of daily living intermediate care facility ICP ICU ID IDDM IDG IM in INC intracranial pressure Intensive Care Unit identification/identify insulin dependent diabetes mellitus Interdisciplinary Group intramuscular inch increase IND inf. inhal. INJ INR Ins. inspir instill. Instr. independent infusion inhalation injection international ratio insurance inspiration, inspiratory instillation instruction INT INT/EXT INTERACTS INTERVENT IOP IPPB IQ internal internal/external interactions interventions intraocular pressure intermittent positive pressure breathing Intelligence quotient Page 10 of 21 14.10 Page 11 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING IR irr., irreg. ITC IV IVF IVP IVT JMH JVD internal rotation irregular Interdisciplinary Team Conference intravenous intravenous fluid IV push intravenous therapy Johnston Memorial Hospital jugular venous distention K+ KAHC potassium Kitty Askins Hospice Center kg L/S/ST LA lab lang. lap LAQ lat kilogram lying, sitting, standing left atrium laboratory language laparotomy long arc quad lateral lb. LBM LBP LBQC LD LE Lg/LGE liq LLB Pound loose bowel movement low back pain large based quad cane learning disability lower extremity large liquid long leg brace LLE LLL LLQ LMH LMP LOB LOC 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 Page 11 of 21 14.10 Page 12 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING LP LPN LPT LR LRAD LUE LUL LUQ LVH lumbar puncture Licensed Practical Nurse Licensed Physical Therapist lactated Ringer's least restrictive assistive device left upper extremity left upper lobe left upper quadrant left ventricular hypertrophy lymph lytes lymphocytes electrolytes m max MCD mcg MCH McK MCL MCRA meter maximum Medicaid microgram mean corpuscular hemoglobin McKesson midclavicular Medicare MCV MD Meas. Meds mEq Mg mg. mgm MGMT MI mean corpuscular volume medical doctor measure medications milliequivalent magnesium milligram management myocardial infarction MIN min ml mm MMT MOD BORG, BORG mod/MOD minimal minimum, minute milliliter millimeter manual muscle test scale to show rate of perceived exertion moderate Page 12 of 21 14.10 Page 13 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING MOM mono MR MRSA MS MSDS MSS MSSP MSW milk of magnesia 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 MVA MVI motor vehicle accident multivitamin MVMT MVP N&V N/A N/S Na NA NaCL movement Mitral Valve Prolapse nausea and vomiting not applicable or not addressed normal saline sodium Nursing Assistant Sodium Chloride NAD neg neuro NG NGT NH3 NHP NIDDM NKA no acute distress negative neurology nasogastric nasogastric tube ammonia nursing home placment noninsulin dependent diabetes mellitus no known allergies No. noc NOC norm. NPI NPO NPU number night, at night Nurse On-Call normal National Provider Identification Number nothing by mouth not picked up Page 13 of 21 14.10 Page 14 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING nsg. NSR NTG NWB O2 O2 sats OA OASIS OB nursing normal sinus rhythm nitroglycerin non weight bearing oxygen Oxygen saturation Osteoarthritis Outcome Assessment and Information Set obstetrics obj OBS object organic brain syndrome occ OD oint OJ OOB OOP OP Opth occasional overdose ointment orange juice out of bed out of pocket ophthalmic ophthalmology OR Ortho; Orth OSHA OSTEO OT OTC OTR/L OX Ox3 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 oz. P PA PAC PAP PARA Pb ounce pulse physician's assistant Port-a-Cath Papanicolaou [test]; peak airway pressure paralyzed lead Page 14 of 21 14.10 Page 15 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING PBI PC PCA PCMH pCO2 PDA PDR PE peds protein bound iodine personal care personal care aide Pitt County Memorial Hospital partial pressure of carbon dioxide patent ductus arteriosus Physician's Desk Reference physical examination, pulmonary embolism pediatrics PEEP PEG positive end-expiratory pressure Percutaneous Endoscopic Gastrostomy per PERF PERLA PERRLA PF pH PICC PID by, through perform pupils, equal and reactive to light and accommodation pupils, equal, round, reactive to light and accommodation plantarflexion hydrogen concentration peripherally inserted central catheter pelvic inflammatory disease PLOF/plof PM PMH PMM PNT/pnt po/PO POA POC polys prior level of function afternoon past medical history Professional Management Meeting patient by mouth power of attorney Plan of Care polymorphonuclear leukocytes poplit pos post postop POT potent. PP popliteal positive posterior, postvocalic (after vowel) postoperative plan of treatment potential postprandial Page 15 of 21 14.10 Page 16 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING PPD preop prep PRES PRN PRNT PROB PROF PROM purified protein derivative preoperative preparation, prepare for present whenever necessary, as needed parent problem professional passive range of motion PT PT/CG physical therapy patient/caregiver PT/INR PTA PTT PV PVC PVD PVR PWB prothrombin time/international normalized ratio physical therapy assistant partial thromboplastin time peripheral vascular premature ventricular contraction peripheral vascular disease post void residual partial weight bearing q q am q2h, q3h, etc. QA QC qid QS R, rt. (R) R/O every every morning every two hours, every three hours, etc. quality assurance quad cane four times a day quad set right rule out R/T RA RBC RBS rd re recep reference to, related to rheumatoid arthritis, right atrium red blood cell, red blood count random blood sugar road regarding receptive Page 16 of 21 14.10 Page 17 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING REM REPS REQ MIN A resp Rh RH RHIA RHIT RLE rapid eye movement repetitions requires minimal assistance respiration, respiratory Rhesus factor right hand Registered Health Information Administrator Registered Health Information Technician right lower extremity RLL RLQ right lower lobe right lower quadrant RML RN RNOC RNS ROM RSC RT RTC right middle lobe Registered Nurse RN On-Call request no service range of motion right subclavian respiratory therapist, therapy return to clinic RTO RUE RUL RUQ RVH RW Rx S s/p return to office right upper extremity right upper lobe right upper quadrant right ventricular hypertrophy rolling walker therapy, treatment, prescription sitting status/post S/S, S&S S/SE SA node SaO2 SAQ SASH SBA signs and symptoms symptoms/side effects sinus-atrial node oxygen saturation in arterial blood short arc quads Saline Antibiotics Saline Heparin stand by assistance Page 17 of 21 14.10 Page 18 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING SE SEC sed rate SGOT SGPT SLB SLP SLR SMA12 side effects secondary sedimentation rate serum glutamic oxaloacetic transaminase serum glutamic pyruvic transaminase short leg brace Speech Language Pathologist straight leg raise sequential multiple analysis of 12 chemistry constituents SMAC SN sequential multiple analyzer with compound skilled nursing SNF SNV SO4 SOB SOC SP SPA SPC Skilled Nursing Facility Skilled Nursing Visit sulfate shortness of breath start of care date Speech Pathologist Spanish single point cane spec. spon., spont SPOU SPT SR SRMC SS SSE ST, SP Tx specimen spontaneous spouse stand/pivot/transfer side rails Sampson Regional Medical Center Social Security soap suds enema speech therapy STAT stim SUBQ Sup SV SVC SW at once stimulation subcutaneous Supervision, supervisory supervisory visit superior vena cava Social Worker Page 18 of 21 14.10 Page 19 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING SWAL Sx, sympt Syl. T&A T, temp T.O. t/f T/F SPT tab swallowing symptoms syllables tonsillectomy and adenoidectomy temperature telephone order transfer transfer (stand, pivot, transfer) tablet TB TBI tuberculosis traumatic brain injury Tbsp TC&DB or TCDB TD TDWB Tech. Ther act Ther ex THR tablespoon turn, cough and deep breathe transdermal touch down weight bearing technique Therapeutic activities therapeutic exercises total hip replacement TIA tid, t.i.d. TKR tol. TPR trach TSA TSH TSM Dressing 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 tsp TT TTB TTWB TUR TURP TV teaspoon transfer training tub transfer bench toe touch weight bearing transurethral resection transurethral resection prostate; Transurethal Prostectomy tidal volume Page 19 of 21 14.10 Page 20 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING Tx UA UB UE UGI UKO umb UNC UR treatment urinalysis upper body upper extremities upper gastrointestinal unknown origin umbilicus, umbilical University of North Carolina Chapel Hill Utilization Review URI UTI upper respiratory infection urinary tract infection VA VAD vag VC/S AD VCS VD Vent via Veteran's Administration/vaginal vascular access device vaginal verbal cues without assistive device verbal cues venereal disease ventilator by way of vit VO vol VP VS w/c w/d w/o w/p, WP vitamin verbal order volume venipuncture vital signs wheelchair warm and dry without whirlpool WBAT WBC WC WFL WilMed wk WMC weight bearing as tolerated white blood cells, white blood count wound care within functional limits Wilson Memorial Hospital week Wake Medical Center Page 20 of 21 14.10 Page 21 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING WMH WND WNL wt. x yr * Wayne Memorial Hospital wound within normal limits weight times year symbols increase increased @ decreased at ~ 2 ° + = Δ > approximate secondary to degree minus, negative plus, positive equal to change greater than < ♂ less than male female ♀ # ÷ % & c p s ā Page 21 of 21 number, pounds divided by percent and with after without before
