title: abbreviations - Community Health Network
advertisement
CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CORP.#: CLN: 3010 Page 1 of 37 EFFECTIVE: 4/12/13 TITLE: ABBREVIATIONS STATEMENT OF PURPOSE: To establish the policy and procedure to govern what abbreviations are approved for use in the medical record and what abbreviations are prohibited from use in the medical record. The Abbreviations Committee will try by policy to comply with the licensing authority of the State and accrediting bodies, e.g. JCAHO. TEXT: 1. The Abbreviations Committee is responsible for reviewing and maintaining the list of Approved Abbreviations and Prohibited Abbreviations. This Committee is multi-disciplinary and consists of members from Health Information Management, Nursing, Pharmacy, Quality Resources, and Physician as well as ad hoc representation from other hospital departments. Any healthcare provider may submit a request for change (additions/deletions) to the listings to the Abbreviations Committee for review. 2. The Abbreviations Committee will approve changes and then submit recommendations for changes to the list to the Medical Executive Committee/Council. The Medical Executive Committee/Council must approve all modifications to this list prior to implementation. 3. The master listing of the Approved Abbreviations and Prohibited Abbreviations will be on the Community Health Network InComm (intranet) and TIHH InComm (intranet), and maintained by the Director of Health Information Management. Listing to be referenced by any health care provider for clarification of abbreviations prior to use. Any abbreviations that are not on the approved list must be written out as the full word. 4. Physician use of abbreviations, prohibited or others that are not on the approved listing will be monitored during chart audit and physicians will be required to write the abbreviation out. This will be monitored by the Health Information Management Department. 5. Prohibited abbreviations written on the Physician Order Form by any healthcare provider must be clarified with that provider and rewritten in the order. The prescribing physician or other healthcare provider writing the Prohibited Abbreviation should be contacted immediately either by telephone or in person. If in the judgment of the individuals providing care to the patient, the order is clear and complete and the delay to obtain confirmation from the prescriber prior to execution of the order would place the patient at greater risk, then the order should be carried out and the confirmation obtained as soon as possible thereafter. 6. Abbreviations are not to be allowed in medical transcriptions. 7. The Approved Abbreviations and Prohibited Abbreviation list must be considered in the development of the Computerized Provider Order Entry (CPOE) system or pre-printed order forms. Formulated by: Approved by: Sub-Committee of Abbreviations Committee Members Abbreviations Committee Date: 4/13 Approved by: CNO Designee Approved: Date: 4/13 Date: Chief Operations Officer CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CORP.#: CLN: 3010 Page 2 of 37 EFFECTIVE: 4/12/13 Do Not Use! list of prohibited abbreviations never to to be used in the medical record PROHIBITED ABBREVIATION U IU Q.D. (QD, qd, q.d.) Q.O.D. (QOD, qod, q.o.d.) CORRECT TERM MISINTERPRETATION Unit International Unit Daily Every other day Trailing zero (X.0 mg) MS, MS04, MgS04 Never write a zero by itself after a decimal point (X mg) Always use a zero before a decimal point (0.X mg) Morphine or magnesium Mistaken as zero, four or cc Mistaken as IV or 10 Mistaken for each other. The period after the Q can be mistaken for “I” and the “O” can be mistaken for “I”. Decimal point is missed ug mcg c.c. ml for milliliters AS, AD, AU, OS, OD, OU Left ear, right ear, both ears, left eye, right eye, both eyes “doses” or “days” Lack of leading zero (.X mg) Ambivalent duration (such as bid x 10 d) Decimal point is missed Confused for one another. Can mean morphine or magnesium sulfate Mistaken for mg (milligram), resulting in one thousand fold overdose Mistaken as U (units) when poorly written Mistaken for each other (AS for OS, AD for OD, etc.) Unclear if (d) means doses or days Note: you will be called for clarification CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CORP.#: CLN: 3010 Page 3 of 37 EFFECTIVE: 4/12/13 before orders can be carried out. ABBREVIATIONS APPROVED FOR USE: @ & a ’d ’s (‘d) = > ‘ “ < % m Ť 1:1 + // ? ŤŤŤ ŤŤ c Psychiatric At And Before Change Changed Changes Check (ed) Decreased; lowered; down Equals Greater than Foot Inches Increased; elevated; up Less than percent Minim Negative No, none One One-to-one therapy Positive parallel bars Question, unknown resulting Three to from Two With CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 s (R) (s) o 1° 1° AVB 1st 2D Echo 2° 2° AVB 2nd 3° AVB 3rd 4th 4x4 5th A AA AAA AAROM Abx AB Ab Ab Scrn Abd ABG ABR AC ac Acc Accel ACE ACL ACLS ACS ad lib ADA ADB Add CORP.#: CLN: 3010 Page 4 of 37 EFFECTIVE: 4/12/13 Without Rectal Supervision Degree Primary First Degree Atrio-Ventricular Block First Two Dimensional Echocardiogram Secondary Second Degree Atrio-Ventricular Block Second Third Degree Atrio-Ventricular Block Third Fourth 4 inch by 4 inch sterile gauze dressing Fifth Assistance Alcoholics Anonymous Abdominal Aortic Aneurysm Active Assisted Range of Motion Antibiotics Abortion Antibody Antibody Screen Abdomen Arterial blood gases Auditory Brainstem Response Auditory Comprehension Before meals Accuracy Acceleration Angiotensin Converting Enzyme Anterior cruciate ligament Advanced Cardiac Life Support Acute Coronary Syndrome At will American Diabetic Association Admission Data Base Adduction CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 ADHD ADL adm adol ADP AE afeb AFL AFO AFP AG AGA AH AHR AI AICD AIDS AIMS AJ AK AKA AKI AlA AlC ALRI ALS AM AMA amb AMI Amnio amp AMRI amt anes Angio ANS CORP.#: CLN: 3010 Page 5 of 37 EFFECTIVE: 4/12/13 Attention Deficit Hyperactive Disorder Activities of daily living Admitted as in-patient Adolescent Adolescent Day Program Adaptive Equipment Afebrile Atrial Flutter Ankle - Foot Orthosis Alpha Feto-Protein Abdominal Girth Average/Appropriate for Gestation Auditory Hallucinations Apical heart rate Aortic Insufficiency Automatic Implantable Cardioverter Defibrillator Acquired immune deficiency syndrome Abnormal Involuntary Movement Scale Ankle jerk Above knee Above-knee amputation Acute Kidney Injury Arthroscopy / arthrotomy Acromioclavicular Anterior lateral rotatory instability Advanced Life Support Morning Against Medical Advice Ambulatory Acute Myocardial Infarction Amniocentesis Ampule Anterior medial rotatory instability Amount Anesthesiology/Anesthesia Angiogram Autonomic Nervous System CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 ant A&O A&P AO AODM AP A/P Repr AP & Lat APB APL approp approx appt Appy APRN APS aq AR ARDS ARF AROM art AS as tol ASA ASAP ASCVD ASD ASHD AT ATC at fib ATA ATB ATN ATT attn aud aug CORP.#: CLN: 3010 Page 6 of 37 EFFECTIVE: 4/12/13 Anterior Alert & Oriented Auscultation and Percussion Aorta Adult Onset Diabetes Mellitus Anterior-posterior Anterior Posterior Repair Anteroposterior & Lateral Abductor Pollicis Brevis Abductor Pollicis Longus Appropriate Approximately Appointment Appendectomy Advanced Practice RN Adult Protective Services Aqueous Aortic Regurgitation Adult/Acute Respiratory Distress Syndrome Acute Renal Failure Active Range of Motion Arterial Aortic Stenosis As Tolerated Aspirin, Acetylsalicylic Acid As soon as possible Arteriosclerotic Cardiovascular Disease Atrial Septal Defect Arteriosclerotic heart disease Activities therapy Activity Therapy Clinician Atrial fibrillation Atmosphere Absolute Antibiotics Acute Tubular Necrosis Anterior tibial tendon Attention Audible Augmentation CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 AV avg AVR Ax B B/B BBOW B/O Bo BA bal BB BBB BBS(CE) b/c BCC BCG BCLS BCS BE Bf BG B-HCG bid bil Bili Bio BIS BIT BK BKA BKO Bld Bld Cult bldng BLS BM BMI BMR BMT CORP.#: CLN: 3010 Page 7 of 37 EFFECTIVE: 4/12/13 Atrioventricular Average Aortic Valve Replacement Axillary Both Bowel and bladder Bulging Bag of Water Because of Bottle Brachial Artery Balance Backward Bending Bundle Branch Block Bilateral Breath Sounds Clear & Equal because Basal Cell Carcinoma Bacille Calmette-Guerin Basic Cardiac Life Support Behavioral Care Services (Psych) Barium Enema Boyfriend Blood Glucose Beta Human Chorionic Gonadotropin Twice a day Bilateral Bilirubin Biological Bispectral Index Behavioral Inattention Test Below knee Below-knee amputation Below Knee Orthosis Blood Blood Culture Bleeding Basic Life Support Bowel movement Body Mass Index Basal Metabolism Rate Bilateral myringotomy tubes CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 BNA BOH BOS BOW B/P BPD BPH BPM BPP Br Br-Hold br sounds Brady BRB bro BRP BS B/S BSA BSC BSO Bst Bst+ BTL BUFA bwd bx c C_ C/A C/D C/D/I c/o CA CABG CAD Cal calc calib Cap CAPD CORP.#: CLN: 3010 Page 8 of 37 EFFECTIVE: 4/12/13 Brief nutritional assessment Back of Hand Base of Support Bag of water Blood pressure Bi-Parietal Diameter Benign prostatic hypertrophy Beats per minute Bilateral pedal pulse Breast Breath Hold Breath Sounds Bradycardia Bright Red Blood Brother Bathroom Privileges Bowel Sounds Bedside Body Surface Area Bedside commode Bilateral salpingo oophorectomy Boost Boost plus Bilateral Tubal Ligation Baby Up For Adoption Backward Biopsy Cup Cervical (with vertebral level) Cardiac and Apnea Clean and Dry Clean, Dry & Intact Complain of Cancer Coronary artery bypass graft Coronary Artery Disease Calorie Calculation Calibration Capsule Continuous Ambulatory Peritoneal CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 cath CAVH CBC CBI CC CCLS CCMS CCTA CDI CDP o C ceph cerv CF CGA Cgh Ch CHA CHD CHE Chemo CHF CHI CHN CHO Chol Chr CHS CI CI/Comm cine circ cl clav cldy CLRT CLS cm cmpd CORP.#: CLN: 3010 Page 9 of 37 EFFECTIVE: 4/12/13 Dialysis Catheter (ization) Continuous Arterio-venous Hemofiltration Complete blood count Continuous bladder irrigation Chief Complaint Certified Child Life Specialist Clean catch mid stream Cardiac CT Angiography Child Depression Inventory Child Day Program Degree Centigrade Cephalic Cervical Cystic Fibrosis Corrected Gestational Age Cough Chair Community Hospital Anderson Congenital heart disease Community Hospital East Chemotherapy Congestive heart failure Community Hospital Indianapolis Community Hospital North Carbohydrate Cholesterol Chronic Community Hospital South Cardiac Index Closed, comminuted Cineangiogram Circumcision Clear Clavicle Cloudy Continuous lateral rotation therapy Community Living Skills Centimeter Compound CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CMV CNS CO COA cog COLD comf cond cong cont contr Conv coor COPD CP CPAP CPC CPD CPM CPP CPR CPS CPT CR Crani CRF CRI CRIT crpt CRRT C&S C-Sect CSII CST CT CTA CTR CTS CORP.#: CLN: 3010 Page 10 of 37 EFFECTIVE: 4/12/13 Cytomegalovirus Central Nervous System Cardiac Output Council on Aging Cognitive Chronic obstructive lung disease Comfortable Condition Congestion Continue/continuous Contraction Conventional Coordination Chronic obstructive pulmonary disease Chest Pain Continuous Positive Airway Pressure Clinicopathological Conference Cephalopelvic Disproportion Continuous Passive Motion Cerebral Perfusion Pressure Cardiopulmonary resuscitation Child Protective Services Chest Physiotherapy Cardiorespiratory Craniotomy Chronic Renal Failure Chronic Renal Insufficiency Critical Care Croupette Continuous Renal Replacement Therapy Culture & Sensitivity Cesarean section Continuous subcutaneous infusion insulin Contraction Stress Test Cat scan Computed Tomography Angiography Carpal Tunnel Release Carpal Tunnel Syndrome CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 cult CV CVA CVAT CVC CVD CVP CVS CVVH CVVHD CVVHDF cx CXR Cysto d DA DAP DAR DAT dau D&C DM DP dt D/O D/l D/W D_ DW DBP DBS DC(‘d) DCA DCC DDX deb decel decomp CORP.#: CLN: 3010 Page 11 of 37 EFFECTIVE: 4/12/13 Culture Cardiovascular Cerebral Vascular Accident Costovertebral Angle Tenderness Central venous catheter Cardiovascular Disease Central venous pressure Cardiovascular System Continuous Venous-venous Hemofiltration Continuous veno-venous hemodialysis Continuous Veno-venous Hemodiafiltration Cervix Chest x-ray Cystoscopy Day Descending Aorta Data, Assessment, Plan Data, Action, Response Diet as tolerated daughter Dilation & Curettage Diabetes Mellitus Dorsalis Pedis Diphtheria, tetanus pediatric Disorder Dry & Intact Distilled water Dorsal (with vertebral level) Dextrose (percent) in Water Diastolic Blood Pressure Dorsal Blocking Splint Discontinue(d) Directional Coronary Atherectomy Diabetes Care Center Desmethyldoxepin Debridement Deceleration Decompensate CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 decr decub defib dehy del dept Dex DF DI DIC Dig. N. dil DIP dis disch Div DJD dk DKA dl. DLC dly DME DNP DNR DOA DOB DOE DOOC DPT Dr. drng drsg DSD DSM DTR DTs DTV DUB CORP.#: CLN: 3010 Page 12 of 37 EFFECTIVE: 4/12/13 Decreased Decubitus Defibrillation Dehydration Delivery Department Dextrostix Dorsiflexion Diabetes Insipidus Desseminated Intravascular Coagulation Digital Nerve Dilatation Distal interphalangeal Distal Discharge(d) Divorced Degenerative joint disease Dark Diabetic ketoacidosis Deciliters Dual Lumen Catheter Daily Durable Medical Equipment Do Not Publish Do Not Resuscitate Dead on Arrival Date of Birth Dyspnea on exertion Diabetes out of Control Diphtheria, Pertussis, Tetanus Toxide Vaccine Doctor Drainage Dressing Dry Sterile Dressing Diagnostic and Statistical Manual Deep Tendon Reflex Delirium Tremens Due to void Dysfunctional Uterine Bleeding CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 DVT Dx DYS DYS1 DYS2 DYS3 DYS4 e (followed by a word) E EFS E-stim ES eg ESF EA EAB EBL EBM ECCE ECF ECMO ECT ED EDB EDC EDD EDO EEG EF EFM EFW EGA EGD EHL EKG elix ELOS EMG EMS CORP.#: CLN: 3010 Page 13 of 37 EFFECTIVE: 4/12/13 Deep vein thrombosis Diagnosis Dysphagia Dysphagia level 1 diet Dysphagia level 1 diet Dysphagia level 3 diet Dysphagia level 4 diet Indication for an electronic format; example eMAR Epidural Enterprise Flowsheet System Electrical Stimulation Extra Strength For example External skeletal fixation Emotions Anonymous Elective Abortion Estimated Blood Loss Expressed Breast Milk Extracapsular cataract extraction Extended Care Facility Extracoporeal Membrane Oxygenation Electro Convulsive Therapy Emergency Department Extensor digitorum brevis Expected date of confinement Estimated date of delivery Emergency Detention Order Electroencephalogram Ejection fraction Electronic fetal monitoring Estimated Fetal Weight Estimated Gestational Age Esophogastroduoenoscopy Extensor Hallucis Longus Electrocardiogram Elixir Estimated length of stay Electromyogram Emergency Medical System CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 EN ENG epith EPL EPS ER ERCP ESRD est estab ESWL ET etc etiol ETOH ETR ETS ETT ETX Ev eval ex exam excis expir ext o F Degree F F.U.O. F/C F/S F/U FA FAS FB FBS FCE fdg FDP CORP.#: CLN: 3010 Page 14 of 37 EFFECTIVE: 4/12/13 Enteral nutrition Electronystagmogram Epithelium Extensor Pollicis Lungus Extrapyramidal symptoms External Rotation Endoscopic retrograde cholangiopancreatography End Stage Renal Disease Estimate Establish Extra-corporeal shock wave lithotripsy Endotracheal And so on Etiology Alcohol Escape to Reality Elevated Toilet Seat Endotracheal Tube Evening Treatment Eversion Evaluation Exercise Examination Excision Expiratory External Farenheit Female Fever of undetermined origin Foley Catheter Frozen section Follow Up Femoral Artery Functional Assessment Score Forward bending Fasting blood sugar Functional Capacity Evaluation Feeding Flexor digitorum profundus CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 FDS fem FES FF FFFB FFP FFWB FH FHR Fi02 fib FIM FL FLACC fld flex flr Flu FM FMLA FOB font for. body FP FPB FPL Fr freq FROM FS FSE ft ftp FTSB FTSG FTSL FTT FU FUES FUES 1 FUES 2 CORP.#: CLN: 3010 Page 15 of 37 EFFECTIVE: 4/12/13 Flexor digitorum superficialis Femoral Functional electrical stimulation Fat Free Foot flat for balance Fresh frozen plasma Flat Foot Weight Bearing Family History Fetal heart rate Fractionated inspiratory oxygen Fibrillation Functional Independence Measure Full liquid diet Face Legs Activity Cry Consolability Fluid Flexion Floor Influenza Fetal movement Family Medical Leave Foot of bed Fontanel Foreign Body Family Practice Flexor pollicis brevis Flexor pollicis longus French Frequent Full range of motion Full strength Fetal Scalp electrode Foot/feet Finger tip Full thickness skin burn Full thickness skin graft Full thickness skin loss Failure to thrive Follow up Functional Upper Extremity Scale Nonfunctional Passive stabilizer CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 FUES 3 FUES 4 FUES 5 FUES 6 FUES 7 func FunclEx FVC FWB fwd Fx g G-tube GA GAF gav GB GBBS GCS GE GERD gest Gf GFR GI GIFT gm GMHC GMHS GPAB gr gs gtt(s) GU Gyn H&H CORP.#: CLN: 3010 Page 16 of 37 EFFECTIVE: 4/12/13 Shoulder < 90%, with no hand manipulation Shoulder < 90% with gross hand manipulation Shoulder> 90%, with gross hand manipulation Shoulder < 90%, with fine hand manipulation Shoulder> 90%, with fine hand manipulation Function Functional Exercise Forced Vital Capacity Full Weight Bearing Forward Fracture Gallop Gastrostomy tube General Anesthesia Global Assessment of Functioning Gavage Gallbladder Group B Beta Strep Glasco Coma Scale Graphic expression Gastroesophageal Reflux Disease Gestation/Gestational Girlfriend Glomerular filtration rate Gastrointestinal Gamete-intrafallopian transfer Gram Gallahue Mental Health Center Gallahue Mental Health Services Gravida Para Abortion Grain Gluteal setting Drop(s) Genitourinary Gynecology Hemoglobin & hematocrit CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 H&P h(r) HI HA HAL HAS HBO HBP Hct HCVD HD HDR HEENT HEP HF HFOV HFV Hgb HHC HHNK HIV HL HMD HNP HOB HOH HP HR HRC HS HSV ht HT HTN hum HUS HVGS HW Hx CORP.#: CLN: 3010 Page 17 of 37 EFFECTIVE: 4/12/13 History and physical Hour Homicidal Ideation Headache Hyperalimentation Hook Addendum Scale Hyperbaric oxygen High Blood Pressure Hematocrit Hypertensive Cardiovascular Disease Hemodialysis High Dose Radiation Head, eyes, ears, nose, and throat Home exercise program Heart Failure High Frequency Oscillator Ventilator High Frequency Ventilation Hemoglobin Healthy Heart Clinic Hyperglycemic, hyperosmolar, non Ketotic coma Human Immunodeficiency Heparin lock Hyaline membrane disease Herniated nucleus pulposus Head of bed Hard of hearing Hotpack Heart rate Hook Rehab Center Hour of sleep/bedtime Herpes simplex virus Height Hubbard Tank Hypertension Humidified Head Ultrasound High Volt Galvanic Stimulation Heparin well History CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 hyst I IA IABP IAH Ib IBD IBS IBW ICC ICH ICP ICS I&D I0 IDDM IDO IDDT ie IEM I/E ratio IF Ig IJ IlL IM IMA Imp IMR IMV in Inc incont INCR ind inf info INH inj IOAP CORP.#: CLN: 3010 Page 18 of 37 EFFECTIVE: 4/12/13 Hysterectomy Independent Intra - arterial Intra-aortic balloon pump Intra-abdominal hypertension Pound Inflammatory bowel disease Irritable bowel syndrome Ideal body weight Interdisciplinary Case Conference Intracranial hemorrhage Intracranial Pressure Intercostal space Incision & drainage Infectious disease Insulin dependent diabetes mellitus Immediate Detention Order Integrated Dual Diagnosis Treatment That is Inborn errors of metabolism/Met Screen Inspiratory to expiratory ratio Intrafat Large Internal jugular Intermittent Infusion Lock Intramuscular Internal mammary artery Impression Image intensifier Intermittent Mandatory Ventillation Inches Incubator Incontinent Increase Induction Inferior Information Isoniazid Injection Intensive Outpatient Addictions CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 IOP Inpt insp inspec int Int PPD I&0 IO IOL ionto IP IPPB IR Irreg Irrig IS ITB IUD IUFD IUGR IUM IUP IUPC IV IVC IVCD IVF IVH IVP IVPB IVSS J tube JP jt jug JVD KAFO Kcal CORP.#: CLN: 3010 Page 19 of 37 EFFECTIVE: 4/12/13 Program Intensive Outpatient Program Inpatient Inspiratory/Inspiration Inspection Interior Intermediate purified protein derivative Intake and Output Intraosseous Intraocular lens IontophoresIs Interphalangeal Intermittent positive pressure breathing Internal rotation Irregular Irrigation Incentive spirometry Iliotibial band Intrauterine device Intrauterine fetal demise Intrauterine growth retardation Intrauterine monitoring Intrauterine pregnancy Intrauterine pressure catheter Intravenous Inferior vena cava Intraventricular Conduction Delay In vitro fertilization Intraventricular hemorrhage Intravenous pyelogram Intravenous piggy back Intravenous soluset Jejunostomy (feeding) tube Jackson - Pratt Joint Jugular Jugular vein distension Knee ankle foot orthosis Kilo calories CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 kg KJ KO KPH KS KVO L L&D L&W LOM L/3 L_ LA lAB lab lac LAD LAO lap lap chole LAQ lat LBBB LBP LBW LCA LCL LCS LCX LDR LDRP LE LGA LGF LHF liq LIS LKS LLE LLL CORP.#: CLN: 3010 Page 20 of 37 EFFECTIVE: 4/12/13 Kilogram Knee Jerk Keep open Key point handouts Kaposi's Sarcoma Keep vein open Liter Labor and delivery Living and Well Left otitis media Lower one-third Lumbar (with vertebral level) Left atrium/atrial Intra-aortic Balloon Laboratory Laceration Left anterior descending Left anterior oblique Laparotomy Laparoscopic cholecystotomy Long arc quad Lateral Left bundle branch block Low back pain Low Birth Weight Left coronary artery Lateral collateral ligament Low continuous suction Left circumflex Labor Delivery Recovery Room Labor, Delivery, Recovery, & Post Partum Lower extremity Large for gestational age Low grade fever Left heart failure Liquid Low intermittent suction Liver, kidneys, spleen Left lower extremity Left lower lobe - lung CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 LLQ LLSB LLT LMD LMP LND Lo Nutr LOA LOB LOC LOP LOS LP LPA LPO LPPC LR LRM LS Lt LTC LTG LTL LTM LTV LUE LUL LUOQ LUQ LV LVH Lytes M M1 MA tube MA-1 MAAS MAE Mall Mammo MAO CORP.#: CLN: 3010 Page 21 of 37 EFFECTIVE: 4/12/13 Left lower quadrant Left lower sternal border Left lateral thigh Local Medical Doctor Last menstrual period lymph node dissection Low nutrient Left occiput anterior Loss of balance Level/loss of consciousness Left occiput posterior Length of stay Lumbar puncture Left pulmonary artery Left posterior oblique Leukocyte poor packed cells Lactated ringers Lateral rectus muscle Lumbo sacral (vertebra) Left Laparoscopic tubal Long term goal Laparoscopy tubal cauterization Long term memory Long term variability Left upper extremity Left Upper Lobe (lung) Left upper outer quadrant Left upper quadrant Left ventricular Left ventricular hypertrophy Electrolytes Male Mitral first Miller-Abbot tube Manual assisted respirator Motor Activity Assessment Scale Moves all extremities Malleolus Mammogram Monoamine oxidase CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 MAP MAR MAS MAW max MBS MCC mcg MCJ MCL MCPJ MD MDI MDD MDN MDTP meas mech med memb mEq mets Met Screen MFR mg mgmt Mgr MHC MI min ML ml MLC mM mm MMPI MMR MMT MN MNT CORP.#: CLN: 3010 Page 22 of 37 EFFECTIVE: 4/12/13 Mean arterial pressure Medication administration record Meconium Aspiration Syndrome Metabolic active weight Maximal assistance Modified Barium Swallow Maternity Care Center Microgram Metacarpal joint Medial collateral ligament Metacarpophalangeal joint Muscular Dystrophy Metered dose inhaler Major Depressive Disorder Multi-disciplinary Note Multidisciplinary Treatment Plan Measure Mechanics Medicine/Medication Membranes Millequivalent Metastasis(es)/metastatic Metabolic Screen Myofascial release Milligram Management Manager Mental Health Clinic/Clinician Myocardial infarct(ion) Minute Midline Milliliter Midline Catheter Milli mole Millimeter Minnesota multiphasic personality inventory Measles, mumps, & rubella vaccine Manual muscle test Midnight Medical Nutrition Therapy CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 mo(s) mob mod MOF MOM MOW MPA MR mr MRA MRDD MRI MRM MRMT MRSA MS M/S MSE MSF MSLT MSOF MT MTP MTPJ MUGA mur MVA mvmt MVPT MVR MWT NOS N/A N/V N/V/D NAD NAS NBN NBQC NBS CORP.#: CLN: 3010 Page 23 of 37 EFFECTIVE: 4/12/13 Month(s) Mobilization Moderate Matter of Fact Milk of Magnesia Meals - On - Wheels Main pulmonary artery Mitral regurgitation may repeat Magnetic Resonance Angiography Mental Retardation Developmentally Disabled Magnetic resonance imaging Medial rectus muscle Minnesota Rate of Manipulation Methicillin Resistant Staph Aureus Multiple Sclerosis Medical/surgical Mental Status Exam Meconium stained fluid Multiple Sleep Latency Test Multiple system organ failure Metatarsal Metatarsophalangeal Metatarsophalangeal joint Multi-Gated Acquisition Scann Murmur Motor vehicle accident Movement Motor free visual perception test Mitral valve replacement Maintenance of Wakefulness Test Not otherwise specified Not applicable Nausea-vomiting Nausea/Vomiting/Diarrhea No apparent distress No Added Salt Newborn nursery Narrow base quad cane Newborn Screen CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 NC ND NDT neb nec NED neg neuro NG NICU NIDDM CORP.#: CLN: 3010 Page 24 of 37 EFFECTIVE: 4/12/13 nil NKA Nasal Cannula No Demands Neurodevelopmental treatment Nebulizer Necessary No evidence of disease Negative Neurology/neurological Naso-gastric Newborn Intensive Care Unit Non-insulin dependent diabetes mellitus Negative inspiratory force National Institute for Health Stroke Scale modified None No known allergies NKDA nm NMB nn. NNP NOB noc norm NP NPC NPH NPO NPP NRB NRP NRT NS NSAID nsg NSR No known drug allergies Nanometer Neuromuscular blockade Nerve Neonatal Nurse Practitioner No other brand Night Normal Nasopharyngeal Non productive cough Isophane Insulin Suspension Nil per os - nothing by mouth Nursing policy and procedure Non rebreather Neonatal Resuscitation Program Neonatal Resuscitation Team Normal Saline Non steroidal anti-inflammatory drug Nursing Normal sinus rhythm NIF NIHSSm CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 NST NT NTG NVC's NWB O O2 OA OATL OB OBRR OBS obsv. OC occ occl OCD OCT OD OFC OG OH OHA oint OJ OK Oligo OM onc OOB OP OPD ophth OPSG OPSM OR ORIF Ortho OSA OT OTA CORP.#: CLN: 3010 Page 25 of 37 EFFECTIVE: 4/12/13 Non-stress test Not tested Nitroglycerin Neurovascular checks Non-weight bearing Objective Oxygen Osteoarthritis Open achilles tendon lengthening Obstetrics Obstetrical Recovery Room Organic Brain Syndrome Observation Open Crib Occasional Occlusive Obsessive Compulsive Disorder Oxytocin challenge test Overdose Occipto-frontal circumference Orogastric Open heart Oral hypoglycemic agent Ointment Orange juice Okay Oligohydramnios Oral motor Oncology Out of bed Outpatient Outpatient department Ophthalmic Overnight Polysomnogram Outpatient sports medicine Operating room Open reduction, internal fixation Orthopaedic Obstructive Sleep Apnea Occupational therapy Open to air CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 OTC ox oz P P02 P2 P/A PA PAC PACU PAT PB PC02 PCA pc PC PCC PCL PCN PCP PCU PCWP PD PDA PDD PE PEARL Peds PEEP PEG per PERL PERLA PERRLA PFC PFT PGAb PH CORP.#: CLN: 3010 Page 26 of 37 EFFECTIVE: 4/12/13 Over the counter Oximetry Ounce Pulse Partial pressure 02 Pulmonic second heart sounds Posterior/Anterior Pulmonary artery Premature atrial contraction Post anesthesia care unit Paroxysmal atrial Tachycardia Piggyback Partial pressure CO2 Patient controlled analgesia After meals Packed cells Pediatric Care Center Posterior cruciate ligament Penicillin Patient Care Pathway Progressive care unit Pulmonary capillary wedge pressure Peritoneal dialysis Patent ductus arteriosis Pervasive Developmental Disorder Pulmonary Embolus/Emboli Pupils equal and reactive to light Pediatrics Positive End Expiratory Pressure Percutaneous Endoscopic Gastrostomy Through/by Pupils equal, react to light Pupils equal, react to light and accommodation Pupils equal round reactive to light and accommodation Persistent fetal circulation Pulmonary Function Test Para Gravida Abortion Past history CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CORP.#: CLN: 3010 Page 27 of 37 EFFECTIVE: 4/12/13 phono PHP PI Phonophoresis Partial Hosp Program Present illness PICC Peripherally Inserted Central Catheter Psychiatric Intensive Care Unit Pelvic inflammatory disease Pregnancy induced hypertension Pitocin Proximal interphalangeal Premature junctional contraction Posterior lateral rotatory instability Peripheral Intravenous Periodic Limb Movement Afternoon/evening Past medical history Point of maximal impuse Premenstrual syndrome Patient not available Premature nodal contraction Patient Not Present Per os Point of Care Preoperative Care Unit Post-operative day(s) Popliteal Positive Posterior After surgery Posterior tibial Post partum Policy and Procedure Post prandial Purified Protein Derivative Plasma protein fraction Persistent Pulmonary Hypertension Post partum ligation Permanent Pacemaker Peripheral parenteral nutrition Palpable pedal pulses PICU PID PIH Pit PIP PJC PLRI PlV PLM PM PMH PMI PMS PNA PNC PNP po POC POCU POD poplit pos Post post-op post. tib PP P&P pp PPD PPF PPHN PPL PPM PPN PPP CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 PPV PR pre-op prec preg premie prep prev prn PROM prox. PS Psych pt. PT PTA PTCA PTL PTP PTSB PTSD` PTSL PUD Pulm PV PVC PVR PWB PZI q qh qid qs QIP QLC qt quant. R ROM RT CORP.#: CLN: 3010 Page 28 of 37 EFFECTIVE: 4/12/13 Positive Pressure Ventilation Per rectum Before surgery Precautions Pregnant Premature infant Prepare for Previous As required Passive range of motion Proximal Pressure sore Psychiatry Patient Physical therapy Prior to admission Percutaneous Transluminal Coronary Angioplasty Preterm labor Post tibial pulse Partial thickness skin burn Post Traumatic Stress Disorder Partial thickness skin loss Peptic ulcer disease Pulmonary Pulmonary vein Premature ventricular contraction Pulmonary vascular resistence Partial weight bearing Protamine zinc insulin Every/each Every hour Four times a day A sufficient quantity Quality improvement process Quadrilumen catheter Quart Quantative Respiration Right otitis media Recreational therapy CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 R/A r/o rad RAT RAV RBBB RC/S RCA RD RDA RDI RDS re Rec rec'd reg rehab REM reps Resp Resp T ret'd retr Rh.A RHC RHD RHF RL RLE RLL RLQ RLS RLT RME RML RNWNP RO ROA ROM ROP RPA CORP.#: CLN: 3010 Page 29 of 37 EFFECTIVE: 4/12/13 Room air Rule out Unit of absorbed radiation Right anterior thigh Readback and verified Right bundle branch block Repeat Cesarean Section Right coronary artery Retinal detachment Recommended daily allowance Reference daily intake Respiratory distress syndrome Regarding Recommendation Received Regular Rehabilitation Rapid Eye Movement Repetitions Respirations Respiratory Therapy Returned Retraction Rheumatoid arthritis Respirations have ceased Rheumatic heart disease Right heart failure Rotation left Right lower extremities Right lower lobe (lung) Right lower quadrant Restless Leg Syndrome Right lateral thigh Right mediolateral episiotomy Right middle lobe (lung) Restricted No Work No Play Reality orientation Right Occiput anterior Range of motion Right occiput posterior Right pulmonary artery CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 RR RROM RSV Rt RTC RUE RUL RUOQ rupt RUQ RV RVH RVSWI RW Rx S S&S SL SOB SS ST s/p S_ SA Sa02 SAB SAH SAQ sat satis SATL SAO SB SBE SBGM SBO SBP sc scap SCC CORP.#: CLN: 3010 Page 30 of 37 EFFECTIVE: 4/12/13 Recovery room Resisted range of motion Respiratory Synctial Virus Right Return to clinic Right upper extremity Right upper lobe (lung) Right Upper Outer Quadrant Ruptured Right upper quadrant Right ventricle Right ventricle hypertrophy Right ventricular stroke work index Radiant Warmer Prescription Single Signs & symptoms Sublingual Short(ness) of breath Soap solution Speech therapy Status post Sacral (with vertebral level) Sinoatrial node Arterial Oxyhemoglobin Saturation Spontaneous abortion Subarachnoid hemorrhage Short arc quads Saturated Satisfactory Subcutaneous Achilles tendon lengthening Sexually Acting Out Side bending Subacute bacterial endocarditis Self blood glucose monitoring Small bowel obstruction Systolic blood pressure Scant Scapula Squamous cell carcinoma CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CORP.#: CLN: 3010 Page 31 of 37 EFFECTIVE: 4/12/13 SCD sch vis/wk SCI SCM SCN SCUF Sequential compression devise Scheduled visits per week Spinal cord injury Sternocleidomastoid Special care nursery Slow continuous ultrafiltration SDS Self directed search of academic, vocational options Side Effects Seconds Seriously Emotionally Disabled Seizure Systolic ejection murmur Separated Sugar free Small for gestational age Social history Shoulder Sacroiliac Sibling Suicidal ideation Syndrome of inappropriate antidiuretic hormone Sudden Infant Death Syndrome Simulation Spontaneous Intermittent Mechanical Ventilation Systemic Inflammatory Response Syndrome Sister Sublingual Slight Systemic Lupus Erythematosus Straight Leg Raising Small Senior Mental Health Clinic Sustained Maximum Inspiration Supportive Matter of Fact Submucous Resection Significant Other Short(ness) of Breath SE sec SED seiz SEM Sep SF SGA SH shldr si Sib SI SIADH SIDS sim SIMV SIRS Sis SL Sl SLE SLR Sm SMHC SMI SMOF SMR SO SOB CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 SOL SOSOB SpGr Spec SPMI SpO2 Spone SPT SR SRM SROM SSCP SSDI SSE SSKI St sta STAT STD STEMI STG stim STM STSG. STV Subcl subQ suct sup supin Supp Surg susp SVC SVD SVE SVO2 SVR SVT Sx CORP.#: CLN: 3010 Page 32 of 37 EFFECTIVE: 4/12/13 Solution Setting on side of bed Specific Gravity Specimen Severely Persistent Mentally Ill Pulse Oximeter Oxyhemoglobin Saturation Spontaneous Standing Pivot Transfer System Review Superior Rectus Muscle Spontaneous Rupture of Membranes Substernal Chest Pain Social Security Disability Soap Suds Enema Saturated Solution Potassium Stain Station At once Sexually transmitted disease ST-elevation myocardial infarction Short term goal Stimulation Short term memory Split thickness skin graft Short term variability Subclavian Subcutaneous Suction(ing) Superior Supination Suppository Surgery Suspension Superior vena cava Spontaneous vaginal delivery Sterile Vaginal Exam Venous oxygen saturation Systemic vascular resistance Supra-ventricular tachycardia Symptom CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CORP.#: CLN: 3010 Page 33 of 37 EFFECTIVE: 4/12/13 Sympat syr syst s/w T T/A T&A TC T&C TAT TcB TD tid TOF TTB T_ TA tab tachy TAH TB TBI Sympathetic Syrup Systolic somewhat Temperature Talked About Tonsillectomy and adenoidectomy Thought Content Type and crossmatch Tetanus antitoxin Transcutaneous bilirubin Thermodilution Three times a day Tetralogy of Fallot Tetanus Toxoid booster Thoracic (with vertebral level) Transactional analysis Tablet Tachycardia Total abdominal hysterectomy Tuberculosis Traumatic brain injury TCDB TCM TcB TcPO2 TCU TDD TED TENS Turn, cough, deep breathe Transcutaneous Monitor Transcutaneous bilirubin Transcutaneous oxygen Transitional Care Unit Tentative discharge date Ted Hose Transcutaneous electrical nerve stimulation Tube feeding Tensor fascia latae Thumb Total hip arthroplasty Therapeutic Activities Therapeutic exercise Total hip replacment Transient ischemic attack Total knee arthroplasty TF TFL Th THA Ther Act Ther Ex THR TIA TKA CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 CORP.#: CLN: 3010 Page 34 of 37 EFFECTIVE: 4/12/13 TKE TKR TL TLC TM TMJ TMP TO toco tol TOM Tomax TP TPA TPM TPN TPR Tpt TPV tr trach trans trap TSA TSF Terminal knee extension Total knee replacement Tubal ligation Triple lumen catheter Treadmill test Temporomandibular joint Trimethoprim Telephone order Tocodynamometer Tolerated Transcutaneous oxygen monitor Maximum temperature Thought Process Tissue Plasminogin Activator Temporary Pacemaker Total Parenteral nutrition Temperature, pulse, respirations Trigger point Trivalent oral polio vaccine Trace Tracheotomy Transferred Trapezius Total shoulder arthroplasty Toilet safety frame TSS TTB TTN TTWB TUR TURBN TURBT Toxic shock syndrome Tetanus Toxoid Booster Transient Tachypna of the Newborn Toe touch weight bearing Transurethral resection Transurethral resection bladder neck Transurethral resection bladder tumor Transurethral resection prostate Television Total vaginal hysterectomy Tidal Volume Treatment Tympanic Urinary output TURP TV TVH TVol Tx tymp U.O. CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 U/3 U/A UAC UAF UAL UBW UC UD UDS UE UF UGI umb uncomf ung. UNK URI UROL US USP UTI UTS UVC UVL V V-P VH V.I.P. VMO VO V/Q VA VAD vag VAS VBAC VComp VCT VD vdg qs VE CORP.#: CLN: 3010 Page 35 of 37 EFFECTIVE: 4/12/13 Upper one-third Urinalysis Umbilical Artery Catheter Universal Assessment Form Umbilical arterial line Usual body weight Ultracal Ulnar deviation Urine drug screen Upper extremity Ultrafiltrate/ultrafiltration Upper Gastro Intestinal Umbilical Uncomfortable Ointment Unknown Upper respiratory infection Urology Ultrasound United states pharmacopeia Urinary tract infection Utility tub seat Umbilical Venous Catheter Umbilical venous line Five Visual perceptual Visual Hallucinations Very important person Vastus Medialis Obliquus Verbal order Ventilation, perfusion quotient Visual acuity Vascular Ventricular assist device Vaginal Visual analog scale Vaginal birth after cesarean Visual comprehension Volume Computed Tomography Venereal disease Voiding quantities sufficient Verbal expression CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 vent VF vit VIU VM VNS Voc Rehab vol VRE VS VSD VSE VSS VT VTM Vtx w W/A W.D. W.N. W.P.W. W/C WB WBAT WBQC WC Wd WFL WIC WIT wk wkly wm WNL WP WPC wt X X-fers X-out XR CORP.#: CLN: 3010 Page 36 of 37 EFFECTIVE: 4/12/13 Ventilator Ventricular fibrillation Vitamin Visual internal urethrotomy Venti mask Visiting nurse service Vocational Rehabilitation Volume Vancomycin resistant enterococcus Vital signs Ventricular septal defect Videofluroscopic swallow evaluation Vital signs stable Ventricular tachycardia Vapotherm Vertex White While Awake Well developed Well nourished Wolfe-Parkinson-White Wheel chair Whole blood Weight bearing as tolerated Wide based quad cane Work conditioning Wound Within functional limits Women's, infants and children Walk in tank Week Weekly Warm Within normal limits Whirlpool Washed packed cells Weight Times Transfers Time out X-ray CORPORATE CLINICAL POLICY AND PROCEDURE Approved For: X CHE X CHN X CHS X TIHH CANCELS: 11/20/12 y/o yd(s) Yr (s) Z z&c ZIFT CORP.#: CLN: 3010 Page 37 of 37 EFFECTIVE: 4/12/13 Years old Yard(s) Years Z-track Zero and calibrate Zygote intra-fallopian transfer Forms with a legend are exempt from this list Periodic table symbols and universally accepted chemical abbreviations are acceptable Hospital Unit Designations are accepted (e.g. 2ST) Abbreviations of laboratory tests that are the same as those used in the laboratory are acceptable Credentials used with signature are acceptable.
