ABBREVIATIONS LISTS
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Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning A A AA AAA A2 A-aDO2 AAROM AB, ab abd abd.gr. ABG ABLA AC ac ACE Inhibitor or ACEI AC Joint ACL ACLS ACS ACTH activ. ACV add. ADH ADHF ADL ad. lib. adm. AE AED AET A-Fib AFL AFO AFV Asian Alcoholics Anonymous abdominal aortic aneurysm aortic component of second heart sound alveolar arterial O2 difference of each active assisted range of motion abortion abdominal abdominal girth arterial blood gas acute blood loss anemia acromo-clavicular before meals (ante cibum) Angiotensin – converting Enzyme Inhibitors acromioclavicular joint anterior cruciate ligament Advanced Cardiac Life Support Acute Coronary Syndrome adrenocorticotrophic hormone activity assist control ventilation addiction antidiuretic hormone acute diastolic heart failure activities of daily living as desired (ad libitum) admit, admission Acute exacerbation Automated External Defibribilator alternating esotropia atrial fibrillation atrial flutter ankle foot orthosis amniotic fluid volume Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning A-F AFB AGA AI AICD AIDS AJ AK AKA AKI Alb ALL ALP ALT (SGPT) AM AMA amb AMI AML AMML amp. AMS amt. ANA anast. ant. Ant. Tib. Ao AOCD A&O Ap a.p. AP APC APD APL approx aq. AR aortofemoral acid fast bacilli appropriate for gestational age aortic insufficiency Automated Implantable Cardioverter Defibrillator Acquired Immunodeficiency Syndrome ankle jerk above knee above knee amputation Acute Kidney Injury albumin acute lymphocytic leukemia Alkaline Phosphatase alanine aminotransferase morning, before noon against medical advice ambulate acute myocardial infarction acute myelocytic leukemia acute myelomonocytic leukemia ampule Altered Mental Status amount antinuclear antibody anastomosis anterior anterior tibial aorta Anemia of Chronic Disease alert and oriented apex/apical antepartum anterior-posterior atrial premature contraction Automated Peritoneal Dialysis abductor pollicis longus approximately aqueous aortic regurgitation Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning ARDS AROM ARF art. AS ASA ASAP ASCVD A.S.D. ASHF A.S.H.D. AST (SGOT) A.T. ATN AV A-V AVD AV Fistula AVI AVM AVR AWOL ax AXT adult respiratory distress syndrome artificial rupture of membranes Acute renal failure arterial aortic stenosis Aspirin as soon as possible arteriosclerotic cardiovascular disease atrial septal defect Acute systolic heart failure arteriosclerotic heart disease Asparate Aminotransferase anterior tibial atubular necrosis atrio-ventricular arteriovenous atrioventricular dissociation Arteriovenous Fistula automatic volume infusion pump arteriovenous malformation aortic valve replacement absence without leave axillary alternating exotropia B B BAL bal. susp. BBB BBT BCLS BCP BE. BF BGM bid BFR bilateral or both blood alcohol level balanced suspension bundle branch block basal body temperature Basic Cardiac Life Support birth control pill barium enema breastfeeding blood glucose monitoring twice a day blood flow rate Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning bili BIH BiPAP BJ BK BKA Bkfst B.M. BME B-Med BMI BMP BMR BNP BO BOC BP BPD BPH BPM BPP BR br BRBPR brp brady BRB BRRB BS BSC BSI BSO BSS BTBV BTL BUN BVT bx, Bx bilirubin bilateral inguinal herniorraphy Bilevel Positive Airway Pressure body jacket below knee below knee amputation breakfast bowel movement biomedical engineering Behavorial Medicine body mass index Basic metabolic panel basal metabolic rate B-type Natriuretic Peptide Bowel obstruction biopsy of cervix blood pressure Bronchopulmonary dysplasia benign prostatic hypertrophy beats per minute biophysical profile bedrest bathroom Bright Red Blood Per Rectum bathroom privileges bradycardia bright red blood bright red rectal bleeding bowel sounds bed side commode body substance isolation bilateral salpingo-oophorectomy balanced salt solution beat to beat variability bilateral tubal ligation blood urea nitrogen bilateral ventilation tubes biopsy Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning C C C1, C2, C3, etc Ca CA CABG CAD CAGE (questions) Cal. ct. CAP CAPD cal. cap cath CAT scan CAVP CB CBC CBD CBDE CBG CCE CCNU CCPD CCRA CCU CD CDH CDHF CDL C&DB CEA cerv CHD Chole, chole CF CHF centigrade cervical vertebra #1, #2, #3 etc Calcium Cancer coronary artery bypass graft coronary artery disease controlling, anger/annoyance, guilt, eye opener Calorie count Community Acquired Pnuemonia continuous ambulatory peritoneal dialysis calorie capsule catheterize, catheterization computerized axial tomography continuous arterial venous pressure Carotid Bruit complete blood count common bile duct common bile duct exploration capillary blood gas clubbing, cyanosis edema lomustine continuous cycling peritoneal dialysis cardiac cath recovery area coronary care unit chemical dependency congenital dislocation hip Chronic diastolic heart failure Circulatory Disorders Lab cough and deep breath carotid endarterectomy or carcinoembryonic disease cervical congenital heart disease cholecystectomy cystic fibrosis congestive heart failure Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning CHI CHO Chol CI CIB CIN circ CIS CIWA CKD Cl CLL cm CMC CMG cmp CMP CMS C.M.S. CNS CNSC C.O. CO2 c/o COC compress cong. cont COPD CORE COWS C&P C&P CPD CMV CPAP CPK/CK CPM CPPV closed head injury carbohydrate Cholesterol cardiac index Carnation Instant Breakfast Contrast Induced Nephropathy circumcision Computer Information System Clinical Intervention and Withdrawal Assessment Chronic Kidney Disease Chloride chronic lymphocytic leukemia centimeter carpo metacarpal cystometrogram cardiomyopathy Comprehensive metabolic panel Centers for Medicare & Medicaid Services color, movement, sensation central nervous system Certified Nutrition Support Clinician cardiac output Carbon dioxide complaining of cauterization of the cervix compression congenital continue chronic obstructive pulmonary disease Center for Medicare & Medicaid Services Clinical Opiate Withdrawal Scale crowning & pushing complete and pushing cephalic pelvic disproportion cytomegalovirus Continuous Positive Airway Pressure creatine phosphokinase Continuous Passive Motion continuous positive pressure ventilation Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning CPR CPT CR creat CRF CRI CRNA CRP CRT C&S C/S, c-section CSF CSHF C.S.S. CST C.T. CT Scan CTA C.T.P. CTS CTSP ctx CV CVA CVC CVP CVS cx Cx CX CXR cysto/Cysto Cardiopulmonary Resustitation Chest Physiotherapy closed reduction creatinine chronic renal failure Chronic renal insufficiency Certified Registered Nurse Anesthetist C-Reactive Protein Cardiac Resynchronization Therapy culture and sensitivity consult Cesarean Section cerebrospinal Fluid chronic systolic heart failure central supply service contraction stress test chest tube computerized axial tomography scan Computerized Tomography Angiography color, temperature, pulse Carpal Tunnel Syndrome called to see patient contraction controlled ventilation/cardiovascular cerebrovascular accident central venous catheter central venous pressure Cardiovascular System cervix/cervical Cancel circumflex chest x-ray cystoscopy D D (T) D1 D2 D3 etc T1, T2 ,T3 DAT dbp etc corsal/thoracic vertebrae diet as tolerated diastolic blood pressure Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning DB&C D&C D/C, disc d/c D.D. D&E decel dept DES devt DFS D/I DIC dil DIP D/G disch., D.C. dissoc. dist. D.J.D. DLH DKA DL-PICC DLVC DM DM Type I DM Type II D.M.I. DNI DNR DMSO DO D/O DOA DOB DOE D.P. DPAP DPT deep breathing and coughing dilatation and curettage discontinue discharge delivery date dilatation and evacuation deceleration department diethylstilbestrol development, develop doppler flow studies dry and intact disseminated intravascular coagulation dilation distal interphalangeal joint double lumen groshong discharge dissociation distal degenerative joint disease double lumen Hickman diabetic ketoacidosis double lumen peripherally inserted central catheter double lumen vascular catheter Diabetes Mellitus Diabetes Mellitus DM Type I Diabetes Mellitus DM Type II diaphragmatic myocardial infarction Do Not Intubate Do Not Resuscitate dimethyl sulfoxide Doctor of Osteopathic Medicine disorder dead on arrival date of birth dyspnea on exertion/date of exam dorsalis pedis diastolic pulmonary artery pressure diphtheria/pertussis/etanus Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning DR dsg d/t DT DTs DTIC DTR DUB DVI DVT d/w DW D/W D5W dx, DX Dz delivery room dressing Due/to diphtheria/tetanus delerium tremors Dacarbazine deep tendon reflexes dysfunctional uterine bleeding deep venous insufficiency deep venous thrombosis Discussed With distilled water dextrose in water dextrose (5%) IN WATER diagnosis/diagnosis Disease E E EBL ECC ECCE ECG/EKG ECHO E. Coli ECMO ECRB ECRL ECT ECV ED E.D. EDC EEG EENT EF EFM EFW enema estimated blood loss endocervical curettage extracapsular cataract extraction electrocardiogram echocardiogram escherichia coli extracorporeal membrane oxygenation extensor carpi radialis brevis extensor carpi radialis longus electroconvulsive therapy extra cellular volume emergency department Erectile dysfunction expected date of confinement electroencephalogram eyes, ears, nose, throat ejection fraction electronic fetal monitor estimated fetal weight Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning EGA EHL elev. Elix EMG EMM EMR EMS EN ENDO Enf ENT EOG EOM eos EP EPB EPEP EPL EPS EPSE ER ERCP ERG ES ESBL ESR ESRD est ET etc. ETOH ETT EUA eval exer exp Expl ext estimated gestational age extensor hallucis longus elevated elixir electromyogram expressed mother’s milk Electronic medical record Emergency Medical Services Enteral Nutrition Endoscopy enfamil ears, nose, throat (otorhinolaryngology) electrooculogram extraocular movement eosinophils Exercise Physiology extensor pollicis brevis end positive expiratory pressure extensor pollicis longus electrophysiologic study extrapyramidal side effects emergency room endoscopic retrograde choledochopancreatography electroretinogram electrical stimulation Extended Spectrum Beta-Lactamases erythrocyte sedimentation rate end stage renal disease estimated endotracheal etcetera, and so on alcohol endotracheal tube examination under anesthesia evaluation exercise expansion exploratory extend, extension Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning Ext extremities F F FA Fa FAS F&C FB FBH FBM FBS FCR FCU fdg Fdg Wt FD FD FDS Fe FECO2 FEM/Fem/fem FHR FIM flex Fevl FF FF@ u FF @ u/1 FFP FH FHT FHx fib Fl02 fl. flex sig Fahrenheit Folic Acid femoral artery fetal alcohol syndrome foam & condoms foreign body football hold fetal breathing movements fasting blood sugar flexor carpi radialis flexor carpi ulnaris feeding Feeding weight forceps delivery fetal demise, death flexor digitorum sublimis iron forced expiratory carbon dioxide femoral fetal heart rate functional independent measure flexion forced expiratory volume fundus firm fundus firm at umbilicus fundus firm at one finger breadth below umbilicus fresh frozen plasma fundal height fetal heart tones family history fibrillation fraction of inspired oxygen fluid flexible sigmoid Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning FM FMC FME FNA FOB font F-P, fem pop FP FPL Fr FR FROM FS ft FT FTI FTN FTT f/u func FUO FVC Fx , fx FWB fetal movement fetal movement chart full mouth extraction fine needle aspiration foot of bed Fontanelle femoral-popliteal flat plate flexor pollicis longus French (such as French Catheter) Friction Rub full range of motion Flow Sheet foot flexor tendon free testosterone index finger to nose failure to thrive follow-up function fever of unknown origin forced vital capacity fracture full weight bearing G G GA gal. GB GDM GE GEA/GETA gen GERD GC GCS GFR gravida gestational age gallon gallbladder gestational diabetes mellitus gastroesophageal general endotrachael anesthesia general Gastroesophageal reflux disease gonorrhea, gonococcus Glasgow Coma Scale glomerular filtration rate Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning g=g GGT GGTP Gh GH GI Glu gm G6PD gr grav GSW GT gtt GTT GU GYN GXT grips equal and good gamma glutamyl transferase gamma gluteryl transpeptidase glenohumeral Growth Hormone or HGH Human Growth gastrointestinal glucose gram glucose-6-phosphate dehydrogenase grain gravida gun shot wound gait training drop glucose tolerance test genitourinary gynecology graded exercise test H H h. HA Ham HB Hb, Hgb HBAg H-BIG HBP hc HC HCAP HCG HCL HCl HCM HCO3 HCP hypodermic hour headache hamstrings head box hemoglogin hepatitis B antigen hepatitis B immune globulin high blood pressure head circumference hydrocortisone Healthcare Associated Pnuemonia human chorionic gonadotrophin hard contact lens hydrochloridic acid hypertrophic cardiomyopathy Bicarbonate health care provider Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning Hct HCTZ HD HDL HDT HEENT HELLP HEMO HEP Hep B Hep C HF HgbA1c or A1c HH H&H HHNK Hib HIC High RA HIM HIPAA HIT HIV HJR HL HM HMD HOH H&P HNP HP HPI H20 Hx/O HOB hpf HPV HR hr hematocrit hydrochlorothiazide hemodialysis High Density Lipoprotein home dialysis training head, eyes, ears, nose and throat hemolysis, elevated liver enzymes, low platelets Hematology home exercise program Hepatitis B Hepatitis C heart failure Glycosylated Hemoglobin Hiatal hernia hemoglobin and hematocrit hyperglycemic hyperosmolar nonketotic (syndrome) Haemophilus Health Information Center high right atrium Health Information Management Health Insurance Portability and Accountability Act Heparin- Induced Thrombocytopenia Human Immunodeficiency Virus hepato jugular reflux heparin lock hand movement hyaline membrane disease hard of hearing history and physical herniated nucleus pulposus hot packs history of present illness water history of head of bed high power field Human Papillomavirus heart rate hour Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning hs HSG HSM HSV ht HT HTLV HTN HUS hx hz hour of sleep or bedtime hysterosalpingogram hepatosplenomegaly herpes simplex virus height hubbard tank Human T-cell Lymphotropic Virus hypertension Hemolytic-Uremic Syndrome history hertz I IABC IABP IABP IBC IBS IBW I-125 I-131 ICA ICCE ICD ICH ICLH ICMP ICP ICU I&D ID IDM IDU IFC IHSS IJ IM, im IMA (L/R) intraaortic balloon counterpulsation intraaortic balloon pressure intra-aortic balloon pump iron binding capacity Irritable bowel syndrome ideal body weight Iodine 125 Iodine 131 internal carotid artery. intracapsular cataract extraction Internal Cardiac Defibrillator Intracerebral hemmorhage Imperial College London Hospital Ischemic Cardiomyopathy intracranial pressure intensive care unit incision and drainage Infectious Disease infant of diabetic mother Idouridizine interferential current idiopathic hypertrophic subaortic stenosis internal jugular intramuscular internal mammary artery-left/right Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning IMP, Imp IMV inf. impression intermittent mandatory ventilation inferior Info ing INH inj INR INSP INT inter I&O IOL IP IPD IPAP IPG IPOC IPPB IPV IR IS ISE isol IT ITP IUD IUFD IUGR IUP IUPC IV IVC IVF IVH IVHA IVIG IVP information Inguinal Isoniazid injury International Normalized Ratio Inspiratory intermittent intermittently intake and output intraocular lens interphalangeal intermittent peritoneal dialysis inspired positive airway pressure impedance plethysmography Interdisciplinary Plan of Care Intermittent Positive Pressure Breathing Intrapulmonary Percusive Ventilation internal rotation incentive spirometry internal spiral electrode isolation intrathecal Idiopathic Thrombocytopenic Purpura intrauterine device intrauterine fetal demise, death intrauterine growth retardation intrauterine pregnancy intrauterine pressure catheter intravenous inferior vena cava intravenous feeding intraventricular hemorrhage intravenous hyperalimentation Intravenous Immunoglobin intravenous pyelogram Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning J J JL JL4 JP JR JR4 Jt JVD Jejunal or Jejunum Judkins left (catheter) Judkins left #4 curve catheter Jackson-Pratt drain junctional rhythm Judkins right #4 curve catheter joint jugular venous distention K K+ KA KC Kcal KC1 KDU kg K.J. KPC KUB potassium ketoacidosis knee chest kilocalories potassium chloride kidney dialysis unit kilogram knee jerk Klebsiella Pneumonia Carbapenemase kidney, ureters, bladder L L L1, L2, etc La LA lab lac LAC LAD LADD LAE LAFa LAFB LAVH Left lumbar vertebra Lactic Acidosis left atrium laboratory laceration left anticubital left anterior descending diagonal branch of the left anterior left atrial enlargement left anterior forearm left anterior fascicular block laparoscopic assisted vaginal hysterectomy Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning lat LB lb. LBBB LBP LBW LCD LCL L Cx L&D LDH LDL LDR LE LEEP LVF LFT LGA LH LHC LIMA liq LLB LLC LLETZ LL LLFa LLL LLW L/Min L/m LMA LMFa LML LMCA L.M.P. LMW LNMP LOA LOC lateral lower body pound left bundle branch block low back pain low birth weight liquor carbonis detergens lateral collateral ligament left circumflex labor and delivery lactic dehydrogenase Low density Lipoprotein labor, delivery, recovery lower extremity loop electro surgical excision procedure left ventricular function liver function test large for gestational age left hand Left Heart Catherization left internal mammary artery liquid long leg brace long leg cast large loop excision of transformation zone left lateral left lateral forearm left lower lobe left lower wrist liters per minute left medial ankle left medial forearm left mediolateral left main coronary artery last menstrual period left medial wrist last normal menstrual period leave of absence level of consciousness Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning LOM LOS LP LPcP LPFB LPN LSO L/S ratio LSC LT LTC LTV LUA LUL LUQ LVG LV LVEF LVH LWS LXT lytes l&w limitation of motion Length of stay lumbar puncture light perception with projection left posterior fascicular block licensed practical nurse left salpingo-oophorectomy lecithin to sphingomyelin ratio left subclavian left tilt low transverse cervical (C/S) long term variability left upper arm left upper lobe left upper quadrant left ventriculogram left ventricle/ventricular left ventricular ejection fraction left ventricular hypertrophy low wall suction exotropia (left) electrolytes living and well M M m m mA mand MAC MAE MAO MAP MAR max MCA MCC mcg. murmur meter meter milliampere mandible, mandibular monitored anesthesia care moving all extremities Monoamine Oxidase Inhibitors mean arterial pressure medication administration record maxilla, maxillary motor cycle accident Motorcycle Collision microgram Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning MCH MCHC MCL MCP MCV MD Mdd MDI mdi ME Med med meds MET mEq MF mg., MHR MHR MI Min MICU MIVF ML ML ml MLC mm MMK mMol MMPI MMR MMT MN mod MOM MP MPAP MR mean corpuscular hemoglobin mean corpuscular hemoglobin concentration medial collateral ligament metacarpal phalangeal mean corpuscular volume medical doctor Major depressive disorder Metered Dose Inhaler manic depressive illness medical examiner medicine medial medicines Medical Emergency Team milliequivalent mid forceps milligram maternal heart rate maximum heart rate myocardial infarction minute Medical Intensive Care Unit maintenance intravenous fluid medication lock midline (episiotomy) milliliter multi lumen catheter millimeter Marshall Marchetti Krantz millimoles Minnesota Multiphasic Personality Inventory measles, mumps, rubella vaccine manual muscle test Midnight moderate milk of magnesia metacarpal phalangeal joint mean pulmonary artery pressure mitral regurgitation Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning MRCP MRI MRSA M/S MS MS MSE MSG MSOF MSR mult mv MVA MVC MVV mv. MVR MVI Medical Resonance Cholagiopancreatography Medical Resonance Imaging Methicillin resistant Staphylococcus aureus Muscoskeletal mitral stenosis multiple sclerosis mental status examination massage / monosodium glutumate multi system organ failure motor sensory reflex multiple millivolt motor vehicle accident Motor vehicle collison maximum ventilatory volume movement mitral valve replacement multivitamin injection N N or nl Na+ NA NA normal sodium nurses’ aide Narcotics Anonymous N/A not applicable not administered, in Medication Administration Check (MAK) system NABS normal active bowel sounds NAD NAT navic NB NBN NC NCAT NCS NE no acute distress Non-Accidental Trauma navicular newborn newborn nursery nasal cannula normocephalic, atraumatic Non-concentrated Sweets neurological examination Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning NEC NED neg NER NG NGR NH3 NI NICMP NICU NIF NIPVL NGT NKA NKDA NKFA NL NM NMS Norm NOS NP NPC NPO NR NQMI NR-NST NSAID NS NSC NSD Nsg NSICU NSR NST NSTEMI NSVD NTB NT necrotizing enterocolitis no evidence of disease negative no evidence of recurrence nasogastric nasogastric replacement Ammonia non immune Nonischemic cadiomyopathy newborn intensive care unit negative inspiratory force non-invasive peripheral vascular laboratory nasogastric tube no known allergies no known drug allergies no known food allergies needle localized non monitored neuroleptic malignant syndrome Normal Not-otherwise specified nasopharyngeal Non-protein Calories nothing by mouth non reactive non Q wave myocardial infarction non-reactive non-stress test nonsteroidal antiinflammatory drug normal saline Nutrition Support Committee normal spontaneous delivery Nursing neurosciences intensive care unit normal sinus rhythm non-stress test Non-ST Elevation Myocardial Infarction normal spontaneous vaginal delivery neural tube defect non tender Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning NTG Nutr NV, n/v nv NVT NW NWB Nitroglycerine Nutrition nausea and vomiting visual acuity for near neurovascular and tendon nursed well non weight bearing O O O2 O2 sat OA OB OB+ OBUS OBS OC’S occ OCT OD OG OGT OJ OMB OOB OOR O and P, O&P OP OPD OPG OPIVT OPV OR ORIF Ortho OS os oral oxygen oxygen saturation osteoarthritis, osteoarthrosis obstetrics occult blood positive obstetrical ultrasound organic brain syndrome oral contraceptives occasionally oxytocin challenge test right eye orogastric orogastric tube orange juice obtuse marginal branch out of bed out of room ova and parasites Outpatient outpatient department oculoplethysmography outpatient intravenous therapy oral polio vaccine operating room open reduction, internal fixation orthopedics left eye mouth Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning OSA OT OU oz Obstructive Sleep Apnea occupational therapy both eyes Ounce P P P2 pa PA P&A PAC PAC PACU PACW PADP PAL PALS palp Pap PAR Para I, II, etc. para PAS pat PAT path, Path PAW PAWP PB PC pc PCA PCKD PCL PCN PCCU PCCR pulse pulmonary component of second sound pulmonary artery Physician’s Assistant percussion & auscultation premature atrial contraction patient access center post anesthesia care unit pulmonary artery capillary wedge pulmonary artery diastolic pressure peripheral arterial line Pediatric Advance Life Support palpable papanicolaou (smear) paraffin having born one child etc. paraplegic para aminosalicylic acid paroxysmal atrial tachycardia preadmission testing pathology pulmonary airway pressure pulmonary artery wedge pressure pudendal block or peripheral blood packed cells after food (post cibum) patient controlled analgesia Polycystic Kidney Disease posterior cruciate ligament penicillin post cardiac cath unit post cardiac cath recovery Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning PCO2 PCOS PCP PCWP PD PDA PD&P PE pe PEA Peds PEEP peg PEG PEJ peron PERRLA PF PFC PFO PFT PG PH, PHx PharmD PHP pH PHI phni PI PICC PICU PID PIG PIH PIP PIP PIV PKU PL partial pressure of CO2 Polycystic Ovary Syndrome Primary Care Provider pulmonary capillary wedge pressure peritoneal dialysis patent ductus arteriosus postural drainage and percussion physical examination pulmonary embolus Pulseless Electrical Activity pediatrics positive end expiratory pressure Percutaneous Endoscopy Gastrostomy pneumoencephalogram Percutaneous Endoscopy Jejunostomy peroneal pupils equal, round, reactive to light and accommodate plasmapheresis permanent flexure contractur Patent Foramen Ovale pulmonary function test phosphatidylglycerol past history Doctor of Pharmacy partial hospitalization program logarithm of reciprocal of hydrogen ion Protected Health Information pinhole no improvement present illness peripherally inserted central catheter pediatric intensive care unit pelvic inflammatory disease pigtail catheter pregnancy induced hypertension peak inspiratory pressure proximal interphalangeal peripheral intravenous phenylketonuria palmaris longus Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning PLL PM PMH PMI PNA PNF PNV po PO2 POCT POD PONV Port. POST post post op PP PP1 PPD PPE PPH PPHN PPN PPPROM PPS PPT PR p=r PRBC PRC PRE pre-op prep PRIT PRN procto prob PROM postero-lateral left afternoon past medical history point of maximum impulse pneumonia propioceptive neuromuscular facilitation prenatal vitamins by mouth (per os) partial pressure of oxygen Point of Care Testing post operative day Post-operative nausea & vomiting portable Physician Orders for Scope of Treatment (r/t Advance Medical Directives) posterior, after post operative post partum post partum day l, etc. Tuberculin Purified Protein Derivative personal protective equipment primary pulmonary hypertension persistent pulmonary hypertension of the newborn peripheral parenteral nutrition Prolonged Preterm Premature Rupture of Membranes postpartum sterilization Partial Prothombin Time pulmonic regurgitation pupils equal and reactive packed red blood cells packed red cells progressive resistive exercises preoperative preparation posterior resection of inferior turbinates as needed (pro re note) proctosigmoidoscopy probable, probably passive range of motion Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning PPROM PRON PRVC prox PS PSA PSCU PT pt PTL Pt PTA PTB PTCA PTE PTL PTX PUD PVC PVD PVR PWB preterm premature rupture of membranes pronation Pressure Regulated Volume Control proximal pulmonic stenosis Prostrate Specific Antigen pediatric special care unit physical therapy Prothombin Time pre-term labor patient prior to admission patellar tendon bearing percutaneous transluminal coronary angioplasty pulmonary thromboembolism preterm labor Pnuemothorax peptic ulcer disease premature ventricular contraction peripheral vascular disease pulmonary vascular resistance partial weight bearing Q q QB qhr q2hr etc qid QMP qns q.s. QS/QS qt. quad QUAD every bloodflow every hour every two hours etc four times per day Qualified Medical Practitioner quantity not sufficient a sufficient quantity intrapulmonary shunting quart quadriceps Quadriplegic R Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning R (R) RA. RA RAC rb RB RBBB rad. RAE RAFa RAM R.B.C. RCA R.D.S. RED. RFt Ref regurg/Regurg REM Resp RET retics RH Rh RHD RL RLL RLQ RLW RLFa RMA R.M.L. RML reps. RMFa RN RNC RND right rectal rheumatoid arthritis right atrium right antecubital right bundle Read Back right bundle branch block radical right atrial enlargement right anterior forearm rapid alternating movements red blood cells right coronary artery respiratory distress syndrome redness, edema, drainage right foot refused regurgitation rapid eye movements respiratory, respirations esotrophia (right) reticulocytes right hand Rhesus rheumatic heart disease right lateral right lower lobe right lower quadrant right lateral wrist right lateral forearm right medial ankle right middle lobe right mediolateral repetitions right medial forearm registered nurse registered nurse certified radical neck dissection Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning RNST R/O ROM ROP ROS RPP RR RRR RSC RSO RSV RT RTC RTUS RUA RUL RUQ Rupt OM RV R-V RVF RVH RVM RVR Rx Rxn RXT RYGB reactive non stress test rule out, ruled out range of motion retinopathy of prematurity review of systems rate pressure product recovery room regular rate and rhythm right subclavian right salpingo oophorectomy respiratory syncytial virus radiation therapy return to clinic routine ultrasound right upper arm right upper lobe right upper quadrant rupture of membranes right ventricle/venticular rectovaginal right ventricular function right ventricular hypertrophy right ventricular mean Rapid Ventricular Response prescription, treatment reaction exotropia (right) Roux-en-y Gastic Bypass S S S-A S1 S2 S3 S4 SA sa sacral sino-atrial lst heart sound 2nd heart sound 3rd heart sound 4th heart sound sinus arrhythmia semen analysis Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning S/A SAC SAH SAQ sat SB sb SBFT SBK SBO sbp SBP sc SCD SCL SCI scol SDAT SDH sec SEM SEMI SF SFe SGA SGOT SGPT SH SHI SHP Si SICU SIDS sim SIMD SIMV SIVP sl SL sugar and acetone short arm cast subarachnoid hemorrhage short arc quads saturate, saturation sinus bradycardia small bowel small bowel follow through spinnbarkeit small bowel obstruction Spontaneous bacterial peritonitis systolic blood pressure subclavian sequential compression device soft contact lens spinal cord injury scoliosis senile dementia-Alzheimer’s type Subdural Hematoma second systolic ejection murmur subendocardial myocardial infarction serum ferritin Serum Iron small for gestational age serum glutamic oxaloaetic transaminase serum glutamic pyruvate transaminase social history standard heparin infusion Hyperparathyroidis Suicidal Idiation surgical intensive care unit sudden infant death syndrome Similar and simplated Substance-Induced Mood Disorder synchronized I.M.V. slow intravenous push slight sublingual Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning SLB SLE SLH SLR SMR SOB sol S/P Sp SPAP Sp gr spec sq SR SROM S/S SSE SSKI SSRI ST st STAT ster STD/STI STICU STSG STV SSS SQ/SC subling sup SVC SVD SVR SVT s/w SWD sx Sz short leg brace systemic lupus erythematosus single lumen Hickman straight leg raise submucous /resection short of breath solution status post sphere systolic pulmonary artery pressure specific gravity specimen squamous sinus rhythm spontaneous rupture of membranes signs & symptoms soap suds enema saturated solution of potassium iodide Selective Serotonin Reuptake Inhibitor sinus tachycardia straight immediately sterile sexually transmitted disease Surgical Trauma Intensive Care Unit split thickness skin graft short term variability short stay surgery subcutaneous sublinqual supination superior vena cava spontaneous vaginal delivery systemic vascular resistance supraventricular tachycardia somewhat short wave disthermy symptoms Seizure Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning T Tl T T3RIA T3RU T4 T&A T Air T App TAR T&C tab tachy TAH TAT TB TBI TBP TCA TCH TCN Tdap or DPT TDWB TED TEE TEF TENS Testost TF TRF T&H THA THR TIA Tib TIBC tid thallium temperature triiodothyronine by radioimmunoassay triiodothyronine by resin uptake thyroxine tonsillectomy & adenoidectomy airpuff tonometry applanation tonometry total ankle replacement type and cross tablet tachycardia total abdominal hysterectomy tetanus antitoxin tuberculosis Traumatic Brain Injury thrombophlebitis tricyclic antidepressants turn, cough, hyperinflate tetracycline Tetanus Diptheria Pertussis Vaccine touch down weight bearing Thrombo Embolic Deterrent transesophageal echocardiogram tracheoesophageal fistula transcutaneous electrical nerve stimulation testosterone tube feeding total fluid removed type and hold Total Hip Arthroplasty total hip replacement transient ischemic attacks tibial total iron binding capacity three times a day Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning TJC TKE TKR TLC TM TMJ TMP TMT TNBP TNF TNM TNS TO tol TORCH TORP tPA TPE TPN TPR tr TR trach TRALI TRH Trig TS TSH TT TT TTP TUR TURP TVH TVol TWE Tx TX The Joint Commission terminal knee extension total knee replacement tender loving care tympanic membrane temporalmandibular joint total membrane pressure treadmill test transurethral needle biopsy of prostate Tumor Necrosis Factor Tumor Nodes Metastosis transcutaneous nerve stimulation telephone order tolerate toxoplasmosis, rebella, cytomegalovirus, herpes total ossicles replacement Tissue Plasminogen Activator total plasma exchange total parenteral nutrition temperature, pulse, respirations trace tricuspid regurgitation tracheostomy Transfusion Related Acute Lung Injury thyroid releasing hormone Triglyceride tricuspid stenosis thyroid stimulating hormone tetanus toxoid tilt table thrombotic thrombocytopenic purpura transurethral resection transuretheral resection of prostate total vaginal hysterectomy Total Volume tap water enema Transplant treatment Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning U UA U/A UAC UAP UC UF UFR UGI ul u/o U/P UPJ URI Urol Uls usa UTD UTI UVC UV UVJ umbilical artery urinalysis umbilical artery catheter unstable angina pectoris uterine contraction ultrafiltration ultrafiltration rate upper gastrointestinal ulnar urine output uretero pelvic uretero pelvic junction upper respiratory infection urology ultrasound unstable angina up to date urinary tract infection umbilical venous catheter umbilical vein uretero vesicle junction V V vag VAS VB VBAC VBG VC vc VCOE VD vent VE VF vision vaginal vibroacoustic stimulator vaginal bleeding vaginal birth after cesarean Venous Blood Gas vascular catheter vital capacity Vascular Center of Excllence venereal disease ventilate vaginal exam visual field Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning VF V-Fib VEP VER vib VIP VLBW VLDL VP VP Shunt vit VO Vol VRE VPC VS vs VSD Vsl VSS vol VT TVol V tach vtx ventricular fibrillation ventricular fibrillation visually evoked potential visual evoked response vibratory sense voluntary interruption of pregnancy Very low birth weight Very Low Density Lipoprotein venous pressure ventricular peritoneal shunt vitamin verbal order volume Vancomycin resistant Enterococcus ventricular premature contraction vital signs versus ventricular septal defect vessel vital signs stable volume ventricular tachycardia Total volume ventricular tachycardia vertex W W WAP w/ wt WB WBAT WBC w/c W/D WD WF white wandering atrial pacer with weight weight bearing weight bearing as tolerated white blood count wheelchair withdrawal well developed waveforms Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning w/f WH WIC w/m WN WNL w/o W/U white female well hydrated women, infants, children white male well nourished within normal limits without Work-up X xfer x-ray transfer radiology Y yo yr year old year Z Zn Zinc FETAL POSITION AND PRESENTATION Abbreviation LOA LOT LOP ROA ROT ROP LSA (RSA)` LST (RST) LSP (RSP) LFA (RFA) LFT (RFT) LFP (RFT) LMA (RMA) LMT (RMT) Meaning left occiput anterior left occiput transverse left occiput posterior right occiput anterior right occiput transverse right occiput posterior left sacrum anterior (right) left sacrum transverse (right) left sacrum posterior (right) left fronto-anterior (right) left fronto-transverse (right) left fronto-posterior (right) left mento-anterior (right) left mento posterior (right) Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning PELVIC MEASUREMENTS (pelvimentry) Abbreviation DC OC bisp. IT Ant. Sag. Post. Sag. AP D Trans D 6F Meaning diagonal conjugate obstetrical conjugate bispinous diameter (interspinous diameter) intertuberous anterior sagittal diameter posterior sagittal diameter anteroposterior diameter transverse diameter #6 French Catheter (cath) SYMBOLS Symbol x Ø ea 1 2 3˚ ♀ ♂ + OO+ /O ~ ii I P ∆ = < > Meaning Except None each primary secondary Add Tertiary female male increase decrease negative positive none about (approximate) two one after change equal less than or equal to greater than Charleston Area Medical Center ABBREVIATIONS APPROVED FOR MEDICAL RECORDS Abbreviation Meaning Æ ® ¬ « // \ / ? ± ↨ # X º none to from to and from parallel bars flexion extension questionable either or up and down pound C with s without times degree
