Approved Abbreviation list
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TITLE: List of Approved Abbreviations REFERENCES: Joint Commission on Accreditation of Healthcare Organization’s comprehensive Accreditation Manual for Ambulatory Care (CAMAC) 200 Standards IM.3 through IM.3.1 OBJECTIVE: To standardize the documentation of medical records and other patient specific information to promote understanding and continuity of care. PROCEDURES: Use of abbreviations, when absolutely necessary, are approved for use at this organization. Abbreviations located in published dictionaries, both Standard English and Medical, are also acceptable. Staff should make every effort to avoid the use of abbreviations whenever possible, and two, notify management of any abbreviations currently in use that do not appear in this document. Review of this procedure will occur at least every two years or as necessary. The following is a summary of the approved abbreviations that can be used in the organization’s medical records and other internal documents of the organization. AB Abortion abd Abdomen a.c. Before Meals ADA American Diabetes Association ADD Attention Deficit Disorder ADHD Attention Deficit Hyperactive Disorder ADL Activities of Daily Living ad lib At liberty, as desired AHA American Hospital Association AHA American Heart Association AIDS Acquired Immunodeficiency Syndrome AKA Above the Knee Amputation aka Also known as Page 1 ALS Advanced Life Support am or AM Morning AMA Against Medical Advice Amb Ambulate Amt Amount Ant or ant Anterior A&O Alert and Oriented AODM Adult Onset Diabetes Mellitus AP Anterior-posterior Appt Appointment Appl Applicator A/R Apical and Radial (pulses) AROM ASA Active Range of Motion Acetylsalicylic Acid or Aspirin ASAP As soon as possible B4 Before BBS Bilateral Breath Sounds BE Barium Enema BID or b.i.d. Twice a day bilat Bilateral BCBS Blue Cross Blue Shield BCN Blue Care Network BCP Birth Control Pill BK Amputation Below the Knee Page 2 BM Bowel Movement BMI Body Mass Index BMR Basal Metabolic Rate BP Blood Pressure BPH Benign Prostatic Hypertrophy BPM Beats per minute, breaths per minute BPS Blood borne Pathogens Standard BS Bowel Sounds or Blood Sugar BSO Bilateral Salpingo-Oophorectomy BUN Blood Urea Nitrogen Bx __ c C Biopsy C (C1, C2) Cervical CA Cancer, Carcinoma CABG Coronary Artery Bypass Graft CATH Catheterization/catheter CBC Complete Blood Count cc Cubic Centimeter CC Chief Compliant CCU Critical Care Unit CDC Center for Disease Control CHD Congenital Heart Disease With Celsius Page 3 CHD Coronary Heart Disease CHF Congestive Heart Failure chole Cholecystectomy CHOL Cholesterol CID Cervical Immobilization Device Cl Chloride CLIA Clinical Laboratory Improvement Amendments cm Centimeter CMA Certified Medical Assistant CNS Central Nervous System c/o Complaints of CO2 COPD Carbon Dioxide Chronic Obstructive Pulmonary Disease CNS Central Nervous System C-PAP Continued Positive Airway Pressure CP Chest Pain, Cerebral Palsy CPAP Continuous Positive Airway Pressure CPB Cardiopulmonary Bypass CPF Creatinine Phosphokinase CPR Cardiopulmonary Resuscitation CRF Chronic Renal Failure CRM Cream C-section Cesarean Section CT Crutch Training Page 4 CTS Carpel Tunnel Syndrome CQI Continuous Quality Improvement CSF Cerebral Spinal Fluid CS or C/S Culture and Sensitivity CT or CAT Computerized Axial Tomography CTA Clear to Auscultation CVA Cerebrovascular Accident CXR Chest X-ray D5W Dextrose 5% in Water DAT Diet as Tolerated DB Deep Breathing DBC Deep Breath and Cough D&C Dilatation and Curettage d/c or DC Discontinue D/I Dry and Intact DJD Degenerative Joint Disease DM Diabetes Mellitus DME Durable Medical Equipment DNR Do Not Resuscitate DO Doctor of Osteopathy DOA Dead on Arrival DOB Date of Birth DOE Dyspnea or Exertion Page 5 DPM Doctor of Podiatric Medicine dr dram DR. Doctor Drng Drainage drsg or dsg Dressing dsd Dry Sterile Dressing DT Delirium Tremens Dt Diphtheria Tetanus DTR Deep Tendon Reflexes DVT Deep Vein Thrombosis DX or dx Diagnosis Dz Disease Echo Echocardiogram ECG Electrocardiogram ECT Enteric Coated Tablet EDC Expected Date of Confinement EEG Electroencephalogram EENT Eyes, Ears, Nose and Throat EF Ejection Fraction EGD Esphagogastroduodenoscopy EH Employee Health EKG (ECG) Electrocardiogram ELX or elix Elixir Page 6 EMG Electromyelograph ENT Ears, Nose and Throat EPA Environmental Protection Agency ER Emergency Room ER External Rotation ERCP Endoscopic Retrograde Cholangiopancreatography ERT Estrogen Replacement Therapy ES Electrical Stimulation et and ETOH Alcohol EX Exercise ext external F Fahrenheit Fri. Friday FA Forearm FB Foreign Body FBS Fasting Blood Sugar F/C Foley Catheter FDA Food and Drug Administration FEF Forced Expiratory Flow FEV Forced Expiratory Volume FF Force Fluids Page 7 FiO2 Fractional Inspired Oxygen Pressure/Concentration FHS Follicle-Stimulating Hormone fld Fluids FOB Foot of bed FP Family Physician Freq. Frequent FU Follow Up FUO Fever of Underdetermined Origin Fx or fx Fracture Fx U/A Fractional Urine FYI For your information Gal or gal Gallon GB Gallbladder GC Gonorrhea GERD Gastro esophageal Reflux Disorder GI Gastrointestinal gm or g Gram gr Grain GR Green GSW Gun Shot Wound gtt or gtts Drop or drops GT Gait Training GTT Glucose Tolerance Training Page 8 GYN Gynecology h or ‘ Hour H2O Water h/a Headache Hb or Hgb Hemoglobin HBP High Blood Pressure HCG Human Chorionic Gonadotropin Hct Hematocrit HEENT Hep A Head, Eyes, Ears, Nose and Throat Hepatitis A Hep B Hepatitis B Hep C Hepatitis C Hgb Hemoglobin H&H Hemoglobin and Hematocrit 5-HIAA 5-Hydroxyindoleacetric Acid HIB Hemapholus B Influenza HIV Human Immunodeficiency Virus HOB Head of Bed HOH Hard of Hearing H&P History and Physical HS Bedtime (hours of sleep) HHN Hand Held Nebulizer HP Hot Packs Page 9 HIP History of Present Illness HRT Hormone Replacement Therapy HR or hr Hour ht or hgt Height HTN Hypertension HVD Hypertensive Vascular Disease Hx History Hyper-seg Hypersegmentation Hypo-Chrom IC Hypochromia Infection Control I&O Intake and Output IVDA Intravenous Drug Abuse IVF Intravenous Fluids IVP Intravenous Pyelogram JCAHO Joint Commission on Accreditation of Health Care Organizations JODM Juvenile Onset Diabetes Mellitus K, k, or K+ Potassium KG or kg Kilogram KUB Kidney, Urethra, Bladder (X-ray) L Liter or Left L (L1, L2, etc) Lumbosacral Lab Laboratory IDDM Insulin Dependent Diabetes Mellitus Page 10 IM Intramuscular IMP Impression INH or inh Inhalation inj Injection Infreq Infrequent Ins Insurance Int. Internal IPPB Intermittent Positive Pressure Breathing IR Internal Rotation IRR Irrigation IU International Unit IV Intravenous Lap Laparotomy Lat or lat Lateral LB or lb Pound LE Lower Extremity, Leg Exercises lg Large LIQ or liq Liquid LLL Left Lower Lobe LLQ Left Lower Quadrant LBM Last Bowel Movement or Loose Bowel Movement LMP Last Menstrual Period LOA Leave of Absence Page 11 LOC Level of Consciousness LOT Lotion LOZ Lozenge LPM or L/M Liters per Minute LPN Licensed Practical Nurse LR Lactated Ringers LTG Long Term Goal LUL Left Upper Lobe LUQ Left Upper Quadrant L&W Living and Well Lytes Electrolytes M or m Meters MA Medical Assistant Ma Medicaid MAE Moves all Extremities MC or Mc Medicare MCA Motorcycle Accident MCG or mcg Microgram MD Medical Doctor MDC Medium Dressing Change MDI Meter Dose Inhaler MDPH Michigan Department of Public Health Page 12 ME Muscle Energy M&E Monitor and Evaluation mEq Mill equivalent MHA Michigan Hospital Association MI Myocardial Infarction Min or min Minute ml Milliliter MM or mm MMR Millimeter Measles, Mumps, Rubella mn Minimum Mo or mo Month Mod Moderate MOM Milk of Magnesia Mon. Monday Mono Mononucleosis, Monocytes M/P Mouth piece MRA Magnetic Resonance Angiography MRI Medical Resonance Imaging MS Multiple Sclerosis MVA Motor Vehicle Accident MVP Mitral Valve Prolapse Na Sodium NA or N/A Not Applicable or Nurses Aide NAD Do Acute Distress Page 13 NB Newborn NC Nasal Cannula Neg. Negative Neuro. Neurology/Neurological NG Nasogastric NIDDM Non-Insulin Dependent Diabetes Mellitus KNA NKDA No Known Allergies No Known Drug Allergies Noc or noc or noct Night Non prod Non productive NPO Nothing by Mouth (nothing per os) NRF or N/R No Refill NS Normal Saline NSR Normal Sinus Rhythm N/T Numbness and Tingling NTG Nitroglycerin N/V Nausea and Vomiting NVD Nausea, Vomiting and Diarrhea NWB Non-Weight Bearing O2 Oxygen O2 Sat Oxygen Saturation OA Osteoarthritis OB Obstetrics Page 14 Obt Obtained OC Oral Contraception Occ Occasional OD Right Eye ONT Ointment OP Outpatient OPV Optho Oral Polio Vaccine Ophthalmology OR Operating Room ORIF Open Reduction, Internal Fixation os Mouth OS Left Eye OSHA Occupational Safety and Health Administration OT Occupational Therapy OTC Over the Counter OU Both Eyes O/W Otherwise OV Office Visit Ovalo Ovalocytes OZ or oz Ounce P After or Pulse PA Pulmonary Artery, Posteroanterior or Physician Assistant Pap Papanicolaou Smear Page 15 pc. Phone call PC After Meals PCN Penicillin PE Physical Education PEG Percutaneous Endoscopic Gastrostomy PERL Pupils Equal and Reactive to Light PERLA Pupils Equal and Reactive to Light and Accommodation PFT Pulmonary Function Test pH Hydrogen Ion Concentrate PID Pelvic Inflammatory Disease Plat Platelets pm Afternoon PM Hx Past Medical History PO Phone Order p.o. Per os (by mouth) Pos. Post Positive Posterior Postop Postoperatively PP Pedal Pulse ppd. Packs per day or TB test Preop Preoperative PRN Whenever necessary, as needed Prob. Probably Prod Productive Page 16 PROM Passive Range of Motion PSA Prostatic Specific Antigen PSNP Patient States Not Pregnant PT Physical Therapy Pt Patient PTA Prior to Admission PT/INR Protime/International Normalization Ratio PTT Partial Thromboplastin Time PUD Peptic Ulcer Disease Pulm. Pulmonary PVD Peripheral Vascular Disease PWB Partial Weight Bearing q Every Page 17 q2h Every two hours q3h Every three hours q4h Every four hours q6h Every six hours q12h Every 12 hours qAM Every morning q.d. Every day q.h. Every hour q.h.s. Every night q.i.d. Four times a day q.n.s. Quantity not sufficient q.o.d. Every other night qPM Every night q.s. Quantity sufficient Qt or qt Quart r Right Rf Refill Re Regarding Resp Respirations RF Rheumatic Fever RHD Rheumatic Heart Disease RHF Right Heart Failure RLQ Right Lower Quadrant Page 18 RM Risk Management RML Right Middle Lobe RN Registered Nurse R/O Rule Out ROM Range of Motion ROS Review of Systems RR Respiratory Rate R/T Related to Rt Right RTC Return to clinic RTK Right to Know Program RUL Right Upper Quadrant Rx Therapy or Prescription _ or s Without samp Sample Sat. Saturday Su/Sun Sunday S/S Saturday/Sunday s/s Signs/Symptoms sbe Self Breast Examination SBP Systolic Blood Pressure SBR Strict Bed Rest SCB Strictly Confined to Bed Page 19 SDC Small Dressing Change Sed Rate Sedimentation Rate SFS Sliding Fee Scale Sig Label SL or Subling Sublingually SLR Straight Leg Raises Sm Small SMDA Safe Medical Devise Act SNF Skilled Nursing Facility S.O. Standing Order SOB Short of Breath Sol Solution S/P Status Post Spec. Specimen Sp. Gr. Specific Gravity Sq. or Sub-q Subcutaneous SR Sedimentation Rate ss One Half SSE Soap Suds Enema S/S Signs and Symptoms STAT, stat, or Stat Immediately or at once STD Sexually Transmitted Disease STG Short Term Goal Page 20 STM Soft Tissue Massage Sup or supp Suppository Surg or surg Surgical SUS Suspension Sxs or Symp Symptom(s) 2’ Secondary to T/Temp Temperature T&A Tonsillectomy & Adenoidectomy Tues. Tuesday TAB, tab or Tab Tablet TAH Total Abdominal Hysterectomy TB Tuberculosis Tbsp or tbsp Tablespoon TC Throat Culture TD Tetanus-Diphtheria TENS Transdermal Electrical Nerve Stimulator Th/Thurs. Thursday TIA Transient Ischemic Attack TIBC Total Iron Binding Capacity TID or t.i.d. Three times a day Tine Tincture TKR Total Knee Replacement TLC Total Lunch Capacity Page 21 TM Tympanic Membranes TMJ Temporomandibular Joints THN/tr. non hem. Transcutaneous Neuromuscular Stimulation TNTC Too numerous to count T.O. Telephone Order Top Topical T/o Throughout Toxic Gran Toxic Granulation TPN Total Parental Nutrition TPR Temperature, Pulse & Respiration TSH Thyroid Stimulating Hormone Tsp Teaspoon TTE Transthoracic Echocardiogram TUR Tran urethral Resection TURP Tran urethral Resection of the Prostrate Tx Treatment or Traction Tyl Tylenol U Unit UA Urinalysis UE Upper Extremity UGI Upper Gastrointestinal ung Ointment URI Upper Respiratory Tract Infection Page 22 US Ultrasound USN Ultrasonic Nebulizer UTI Urinary Tract Infection V.A. Veterans Administration Vag or vag Vaginal VD Venereal Disease VNA Visiting Nurses Association USD Use as directed V.O. Verbal Order Vol or vol Volume VS Vital Signs VSS Vital Signs Stable W or Wed Wednesday WA Wide Awake WB Weight Bearing WBC White Blood Cells W/C Wheel Chair W.D. Warm and Dry WDW Well Developed White W/F White Female W/M White Male Wk Week WNL Within Normal Limits Page 23 WP Whirlpool WP-A Whirlpool with Additives WP-D Whirlpool with Debridement WP-EXD Whirlpool with Extensive Debridement WP-ST Whirlpool with Sterile Technique Wt Weight Yel Yellow Yr Year Yrly Yearly 0x3 @ Signs and Symbols Oriented to Person, Place & Time At Page 24 > Above (greater than) ~ Approximate < Below (less than) __ Change __ Check Decrease . Degrees = Equal _ Female Heart Increase L Left -- Male (-) Negative or Minus 0 or Not equal # Number or Pound + Positive or Plus R Right ? Questionable or Undertermined 2^ Secondary Degree X Times Page 25
