Approved Abbreviations for Use in Medical Records january 16
advertisement
TRI-COUNTY HEALTH CARE CONSORTIUM Policy: Approved Abbreviations for Use in Medical Records Policy Manual: Clinical Approved: ______________________________Date: _______________________ Revised: _______________________________Date: ________________________ Policy: To avoid misinterpretation, symbols and abbreviations are used in the medical record only when they have been approved by the Medical Staff (Providers) and when there is an explanatory legend available to those authorized to make entries in the medical record and to those who must interpret them. Guidelines: 1.) A copy of this policy will be maintained in each providers office, all patient care/nursing areas and each medical records file room. 2.) Any proposed additions or deletions to the list will be directed to the medical director, to be taken to the providers for consideration. OTC’S APPROVED SYMBOLS AND ABBREVIATIONS LISTING SYMBOLS: # ? % & ◦ + +/< @ ↓ ↑ ♀ ♂ - Number question percent and Degree positive positive or negative less than greater than at Decreased Increased or elevated Female Male negative 1 ABBREVIATIONS -AA.A. AAA ab abd Abd Hyst ABG ABI abn Abx AC a.c. Acid Phos ACL ACLS ACOS ACTH A.D.A. ADA ADDM ad lib ADL adm adj AFB AHA AICD AK AKA Alk phos a.m. A.M.A. AMA amb AMD AMI amp Amt ANA ant ante AP AP & lat Alcoholics Anonymous Abdominal Aortic Aneurysm abortion abdomen abdominal hysterectomy arterial blood gases ankle brachial indices abnormal antibiotics acromioclavicular before meals acid phosphatase anterior cruciate ligament advanced cardiac life support American College of Surgeons adrenocorticotrophic hormone American Disability Act American Diabetic Association adult onset diabetes mellitus as desired activities of daily living admission adjustment acid fast bacillus American Heart Association Automatic Implantable Cardioverter Defibrillator above knee above knee amputation Alkaline Phosphatase before noon American Medical Association against medical advice ambulatory Advanced Medical Directive acute myocardial infarction ampule amount Antinuclear antibody anterior before or pre anteroposterior Anterior, posterior and Lateral 2 AP repair approx appt. ARDS ARF A.S. ASA ASAP As tol. ASCVD ASD ASHD Aso titer Asst Atm A.U. AV AVF aVF aVL aVR AVR Anterior & Posterior repair approximate appointment Acute Respiratory Distress Syndrome acute renal failure left ear aspirin as soon as possible As tolerated arteriosclerotic cardiovascular disease atrial septal defect arteriosclerotic heart disease anti-streptolysis titre assistance atmosphere of pressure both ears aortic valve arteriovenous fistula augmented unipolar ECG leads augmented unipolar ECG leads augmented unipolar ECG leads Aortic Valve Repair/Replacement -BBBB BCC b.i.d. Bilat Bili BIPAP BK BKA Bld BM BMI BMR BMT BP BPH BRP BS BSA BSO BTL BUN bundle branch block basal cell carcinoma twice daily bilaterally bilirubin Bi-Level Positive Airway pressure below the knee below knee amputation blood bowel movement Basal Metabolic index basal metabolic rate bilateral myringotomy tubes blood pressure benign prostatic hypertrophy bathroom privileges blood sugar Body surface area bilateral salpingo-oophoectomy bilateral tubal ligation blood urea nitrogen 3 Bx biopsy -Cc C1, C2 C&S Ca CA CABG CAD Cal Cap CAT Scan Cath CBC CC CCA CCU CDC chemo CHF Circ Cl cm CMN CNS c/o CO2 Coag COLO COPD CP CPAP CPD CPK CPR CQI CRF C-section CSF CT ct CT scan CTA cult with first cervical vertebra; second cervical vertebra, etc. culture and sensitivity calcium carcinoma coronary artery bypass graft coronary artery disease calorie capsule computerized axial tomography scan catheter (ize) complete blood count chief comlaint Common Carotid Artery coronary care unit Centers for Disease Control chemotherapy congestive heart failure circumcision chloride centimeter Childrens Miracle Network central nervous system complains of carbon dioxide coagulation Colonoscopy chronic obstructive pulmonary disease Cerebral Palsy continuous positive airway pressure cephalopelvic disproportion creatine phosokinase cardiopulmonary resuscitation Continuous Quality Improvement chronic renal failure Cesarean section cerebrospinal fluid chest tube count computerized axial tomography scan clear to auscultation culture 4 CV CVA CVD CVP Cx CXR cysto cardiovascular cerebrovascular accident cardiovascular disease central venous pressure cervix chest xray cystoscopy -D/d d D&C D&E D-5-S D-5-W D1, D2 , dB DDS Demo dept DES DFS DIC diff Dig DIP DJD DKA D/L/R DM DME DNR DO DOA DOB DP DPT dsg DT DTR DVT D/W Dx per day day, 24 hours dilatation and curettage dilation and evacuation dextrose (5%) in saline dextrose (5%) in water 1st dorsal (thoracic) vertebrae,, 2nd dorsal (thoracic vertebrae) decibel Doctor of Dental Surgery demostrate department diethylstilbestrol Division of Family Services (MO) disseminated intravasular coagulation differential blood count digoxin distal interphalangeal (joint) degeneraative joint disease Diabetic Ketoacidosis dextrose/lactated/ringers diabetes mellitus durable medical equipment do not resuscitate Doctor of Osteopathy dead on arrival date of birth Dorsalis Pedis diphtheria, pertusis, tetanus dressing delirium tremens deep tendon reflex deep vein thrombosis dextrose in water diagnosis 5 -EEBL ECCE ECG E.coli ECT Ed ED EDC EEA EEG EENT EFM e.g. EGD EKG emerg EMG EMS ENT EOM Eosin ER ERCP ESR ESRD Est. E-stim ESWL et ET-Tube ETOH EUA eval exam exc Exp. Lap estimated blood loss extracapsular cataract extraction electrocardiogram Escherichia coli electroconvulsive therapy (electroshock) Education Emergency Department expected date of confinement end-to-end anastomosis electroencephalograph ear, eye, nose and throat external fetal monitor for example esophagogastroduodenoscopy electrocardiogram emergency electromyogram emergency medical services ears, nose and throat extraocular movement eosinophils emergency room endoscopic retrograde cholangiopancreatogram erythrocyte sedimentation rate end stage renal disease estimated electrical stimulation extracorporeal sound wave lithotripsy and endotracheal tube alcohol examination under anesthesia evaluate: evaluation examination; examined excision exploratory laparotomy -F5-FU F FACP FACS 5-Flourouracil female Fellow of the American College of Physicians Fellow of the American College of Surgeons 6 FB FBS FDA Fe FESS FEV1 FFP FH FHR FHT fib fl fl. oz. Flex flu fluoro FM FOB FOV F.P. fract. frag. freq. FS FSH FT ft. FTSG F/U func FUO Fx foreign body fasting blood sugar Food and Drug Administration iron functional endoscopic sinus surgery Forced expiration volume in one second fresh frozen plasma family history fetal heart rate fetal heart tone fibrillation fluid fluid ounce flexion influenza fluoroscopy fetal monitor foot of the bed field of vision family physician fracture fragment frequent frozen section follicle-stimulating hormone feeding tube foot; feet full thickness skin graft follow-up functional fever of unknown origin fracture -GG G-tube gal GB GC Gen GERD GGT GI Glu. gm. gravida gastrostomy tube gallon gallbladder gonococcus; gonorrhea general gastroesophageal reflux disease gamma glutamic trasaminase gastrointestinal glucose gram 7 gr. grav GSW GTT gtt. GU GYN Grain gravid (pregnant) gunshot wound glucose tolerance test drops genitourinary gynecology -Hh H20 H202 HC03 H&H H&P H/A HCG HCT HD HDL HEENT HF Hg Hgb H/H HHS HIV HNP HOB HOH hosp. HPI HR hr. h.s. ht. HTN HVD Hx hyper hypo hyst Hz hour water hydrogen peroxide bicarbonate hemoglobin and hematocrit history and physical headache human chorionic gonadotropin hematocrit hemodialysis high density lipoprotein head, eyes, ears, nose, and throat heart failure mercury hemoglobin hemoglobin and hematocrit Department of Health and Human Services human immuno virus herniated nucleus pulposus head of bed hard of hearing hospital history of present illness heart rate hour at bedtime height hypertension hypertensive vascular disease history above or high hypodermic injection; low hysterectomy hertz 8 -II&D I&O I131 IABP IBS ICP ICU ID IDDM i.e. Ig IM IMP: in. in situ in utero info. Ing inj. INR Ins. int IO IOL IOP IP IPPB IQ ITP IUD IUP IUPC IV IVP IVPB incision and drainage intake and output radioactive iodine intra-aortic balloon pump irritable bowel syndrome intracranial pressure intensive care unit identification insulin dependent diabetes mellitus that is to say immunoglobulin intramuscular impression inch confined to the site of origin within the uterus Information inguinal Injury International Normalized Ratio insurance internal intraocular intraocular lens intraocular pressure intraperitoneal intermittent positive pressure breathing intelligence quotient idiopathic thrombocytopenic purpura intrauterine device intrauterine pregnancy intrauterine pressure catheter intravenous (ly) intravenous pyelogram intravenous piggy back -J-Kk K KCL 1000 potassium potassium chloride 9 kg. KUB kilogram kidney, ureter, and bladder -Ll L1, L2, etc lab LAD LAO lat LAVH lb. LBBB LDH LDL LE lg LH Li lig. liq. LLL LLQ LMP LOA LOC L.O.C. LOS LP LPN L-S LSH Lt. or l ltd LTL LUQ LV LVH lmphs lytes liter first lumbar vertebra, second lumbar vertebra, etc. laboratory left anterior descending left anterior oblique lateral laparoscopic assisted vaginal hysterectomy pound left bundle branch block lactate dehydrogenase low density lipoprotein lower extremity large luteinizing hormone lithium Ligament Liquid left lower lobe/lung left lower quadrant last menstrual period leave of absence local loss of consciousness length of stay lumbar puncture licensed practical nurse lumbo-sacral lutein stimulating hormone left limited laparoscopic tubal ligation left upper quadrant left ventricle left ventricular hypertrophy lymphocytes electrolytes -MM m. male meter 10 MAR MAST trousers max mcg MCHC MCV MD Menomet mets mEq Mg mg MgS04 mgmt MI micro min ML ml MMK MMPI mod MOM mono MP mph MRI MRSA MS M.S. MVA MVP MVR medication administration record military antishock trousers maximum micrograms mean corpuscular hemoglobin concentration mean corpuscular volume medical doctor menometrorrhagia metastases milliequivalents magnesium milligram magnesium sulfate management myocardial infarction microscopic minute midline milliliter Marshall-Marchetti Krantz Minnesota Multiphasic Personality Inventory moderate milk of magnesia monocytes metacarpo-phalangeal (hand) miles per hour magnetic resonance imaging methacillin resistant staphylococcus aureus multiple sclerosis Master of Science motor vehicle accident mitral valve prolapse Mitral Valve Replacement/Repair -NN20 N&V N.A. N/A Na NaC1 NB NBN neg Neuro nitrous oxide nausea and vomiting Narcotics Anonymous not applicable sodium sodium chloride newborn newborn nursery negative neurology 11 NG NH Nitro NKA NKDA NO noct norm NOS NPH NPO N/S NSAIDS NSR NST NSY N/V N/V/D NWB nasogastric nursing home nitroglycerin no known allergies no known drug allergies nitrous oxide night normal not otherwise specified neutral protamine Hagedorn (Insulin) nothing by mouth normal saline nonsteroid anti-inflammatory drugs normal sinus rhythm nonstress test nursery nausea/vomiting nausea, vomiting and diarrhea non-weight bearing -OO 02 OB OB-Gy n obs occ OCG O.D. OD oint OM OMT OOB O/P OPC OPD O&P OR ORIF Ortho os OS OSA OSHA orally oxygen obstetrics obstetrics-gynecology observe; observation occasional oral cholecystogram right eye overdose ointment otitis media osteopathic manipulative therapy out of bed outpatient outpatient clinic outpatient department ova and parasites operating room open reduction with internal fixation Orthopedics mouth left eye Obstructive Sleep Apnea Occupational Safety & Health Administration 12 OT OU oz occupational therapy (ist) both eyes ounce -Pp P P.A. PA PAC Pap smear PAR Para PAT Path PBI p.c. PC02 PCP PD PDA P. E. PE PEDS PEEP PEG PERLA PFT pg pH PH PI PID PIT PKU Plat. p.m. PMH PMI PM&R PMS po PO2 PO4 polys after Para physician assistant posterior anterior premature atrial contraction papanicolaou smear post anesthesia recovery parous, parity paroxysmal atrial tachycardia pathology protein bound iodine after meals partial pressure carbon dioxide Primary Care Physician peritoneal dialysis patent ductus arteriosis pulmonary embolus physical examination pediatrics postive end-expiratory pressure Percutaneous Endoscopic Gastrostomy pupils equal, react to light pulmonary function test pregnant hydrogen ion concentration past history present illness pelvic inflammatory disease pitocin phenylketonuria Platelets afternoon or evening past medical history point of maximal impulse physical medicine and rehabilitation premenstrual syndrome by mouth, orally partial pressure oxygen phosphate polymorphonuclear leukocytes 13 pos post-op post pre-op preg prep prev. PRN procto protime PSA psych PT pt. PTCA PTH PTT PUD pulm PVC PVD PX positive post-operative posterior preoperative pregnancy preparation previous when needed proctoscope prothrombin time Prostatic Specific Antigen psychiatric; psychology physical therapy patient percutaneous transluminal coronary angioplasty parathyroid hormone partial thromboplastin time peptic ulcer disease pulmonary premature ventricular contractions peripheral vascular disease physical examination -Qq QA q.am q2h q.h. qhs qid QM QNS q4h QRS qs qt. quad every quality assurance every morning every two hours every hour at bedtime four times daily quality management quantity not sufficient every 4 hours segment of electrocardiograph quantity sufficient quart quadraplegia; quadraplegic -RResp. RA RAO RBBB respirations rheumatoid arthritis right anterior oblique right bundle branch block 14 RBC RCA RD RDS rec Re-eval reg Rehab REM resp Retic.Count RF Rh R/L RLE RLL RLQ R/O RM RML RN ROM rpm RRR RSR RT Rt. or ® RTC RTN RTO RUE RUL RUQ Rx Rxn red blood count right coronary artery registered dietitian respiratory distress syndrome recommend; recommendation reeavaluation regular rehabilitation rapid eye movement respiration reticulocyte count rheumatoid factor rhesus (with reference to blood factors) ringers lactate right lower extremity right lower lobe right lower quadrant rule out room right mediolateral registered nurse range of movement revolutions per minute regular rate and rhythm regular sinus rhythm rspiratory therapy right return to clinic return return to office right uper extremity right upper lobe right upper quadrant prescription Reaction -Ss S04 S-A S&O Sa02 sats SBO sed without sulfate sino-atrial salpingo-oopherectomy oxygen saturation saturation small bowel obstruction sedimentation 15 sedrate segs SGOT SGPT SIADH Sibs sl SLE sm SNF SNU SOAP SOB soc hx Sol. SOP S/P Sp.gr. Spont. SR S/S STD Staph Stat STO Strep STSG Subq. Surg SVC Sx erythrocyte sedimentation rate segmented neutrophils (polymorphonuclear leucocytes) serum glutamic oxaloacetic acid transaminase serum glutamic pyruvic transaminase syndrome of inappropriate antidiuretic hormone siblings sublingual systemic lupus erythematous small skilled nursing facility skilled nursing unit subjective; objective; assessment; plan shortness of breath social history Solution standard operating procedure status post specific gravity Spontaneous sinus rhythm signs and symptoms sexually transmitted disease staphylococcus at once, immediately short-term observation streptococcus split thickness skin graft Subcutaneous surgical; surgery superior vena cava symptoms -TT T&A T&C T&S T3 T4 Tab TAH TB tbsp TEE temp. temperature tonsil(ectomy) and adenoid (ectomy) type and crossmatch type and screen triiodothronine thyroxine tablet total abdominal hysterectomy tuberculosis tablespoon transesophageal echocardiogram temperature 16 TENS TIA TIBC t.i.d. TLC TM TNTC TO tol TPN TPR trach. TSH tsp. TURP TV TVH tx transcutaneous electrical nerve stimulation transient ischemic atttack total iron binding capacity three times daily total lung capacity tympanic membrane too numerous to count Telephone order tolerated total parenteral nutrition temperature, pulse and respiration Tracheostomy thyroid stimulating hormone teaspoon transurethral resection of prostate tidal volume total vaginal hysterectomy treatment -UUA UCG UC&S UE UGI unilat URI Urol UTI UV urinalysis urine chorionic gonadropin (pregnancy test) urine culture and sensitivity upper extremity upper gastrointestinal unilateral upper respiratory infection urology urinary tract infection ultra-violet -VV vag. Vanco VBAC VC VD VDRL vent V-fib via vit. VLDL volume vaginal Vancomycin vaginal birth after cesarean section vena cava veneral disease veneral disease research laboratory (syphillis serology test) ventilator ventricular fibrillation by way of Vitamin very low density lipoprotein 17 VO voc vol. VRE VS vs. VSD V-tach VTX verbal order vocational volume Vancomycin Resistant Enterococcus vital signs versus ventricular septal defect ventricular tachycardia vertex -Ww/ WB WBC w/c W/F WIC W/M WNL W/O wt. with whole blood white blood cell (count) wheelchair white female Women, Infants, Children Nutrition Program white male within normal limits without weight -XX X-ray X’s XX XY sign of multiplication roentgen rays times normal female chromosome type normal male chromosome type -Yyd y/o yr yard years old year -Z- 18 19
