West Side Community Health Services
Manual
Clinical
Subject
Abbreviations
_X_ Policy ___ Procedure
Page 1 of 13
Category
Effective
Approval
Medical
1/00
Medical Director
Executive Director
Policy:
West Side Community Health Services uses standardized abbreviations and symbols in its
medical record documentation:
AAA
AAROM
AB
ABDHyst
ABG
ac
AC
ACEI
ACTH
ACL
ad.
ad lib
ADA diet
ADAP
ADAT
ADC
ADH
ADL
adm
AFib
AFB
AFO
AGA
A/G ratio
AI
AK
AKA
Alb.
ALS
AM
AMA
amt.
anat.
ant.
ante
A&P
abdominal aortic anuerysm
Active assistive range of motion
abortion
Abdominal Hysterectomy
arterial blood gas
before meals
acromioclavicular
angiotensive converting enzyme
Adrenocorticotrophic hormone
Anterior cruciate ligament
to; up to
as much as needed; as desired
American Diabetic Association diet
Alcohol and Drug Abuse Program
advance diet as tolerated
Adult Detention Center
Anti-diuretic Hormone
Activities of daily living
Admission
Atrial Fibrillation
Acid Fast Bacilli
Ankle foot orthosis
Appropriate for gestational age
albumin-globulin ratio
aortic insufficiency
above the knee
above the knee amputation
albumin
amyotorphic lateral sclerosis
morning
against medical advice
amount
anatomy; anatomical
anterior
before
auscultation and percussion
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
A-P
aptt.
aq
ARC
ARDS
AROM
AROM
AS
ASA
ASCVD
ASD
ASHD
A-V
AV
AVR
anterior/posterior
activated partial thromboplastin time
aqueous
AIDS related complex
adult respiratory distress syndrome
active range of motion
artificial rupture of membranes
aortic stenosis
aspirin
atherosclerotic cardiosvascular disease
atrial septal defect
atherosclerotic cardiovascular disease
arteriovenous
arterioventricular
aortic valve replacement
BAER’s
BAD
BAL
BCG
BHCG
b.i.d.
BK
BKA
BM
BMR
BP
BPD
BPH
BRAT
BRBPR
BRP
BS
BS
bs
BSF
BSO
BTL
BUN
Bx
brain stem auditory evoked responses
bipolar affective disorder
bronchial alveolar lavage
vaccine for TB
beta human chorionic gonadotropin
twice a day
below the knee (amputee)
below the knee amputation
bowel movement
basal metabolic rate
blood pressure
bronchopulmonary dysplasia
benign prostatic hypertrophy
banana, rice, apples, toast
bright red blood per rectum
bathroom privileges
blood sugar
bowel sounds
breath sounds
basilar skull fracture
bilateral salpingo-oopherectomy
bilateral tubal ligation
blood urea nitrogen
biopsy
c
C.
C
Ca
ca
CAB
CABG
with
centigrade
cervical
calcium
cancer; carcinoma
coronary artery bypass
coronary artery bypass graft
Page 2 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
CAD
cap.
C.A.T.
cath
CBC
CC
cc
CD
CEA
cg
CHF
CHI
chole
Cl
cm
CMG
CMS
CMV
CNS
c/o
CO
CO2
COPD
CPD
CPR
CS
CSF
C-spine
C.T.
CT
cu
CUG
CV
CVA
CVP
CW
CXR
coronary artery disease
capsule
computerized axial tomography; CT
catheter; catheterization
complete blood count
chief complaint
cubic centimeter
chemically dependent
carcino-embryonic antigen
centigram
congestive heart failure
closed head injury
cholecystectomy
chloride
centimeter
cystometrogram
capillary filling, movement and sensation
cytomegalovirus
central nervous system
complains of
carbon monoxide
carbon dioxide
chronic obstructive pulmonary disease
cephalopelvic disproportion
cardiopulmonary resuscitation
C-section
cerebrospinal fluid
cervical spine
computerized tomography – CAT
chest tube
cubic
cystourethrogram
cardiovascular
cerebrovascular accident
central venous pressure
consistent with
chest X-ray
d/c
D/C
D&C
DAT
DBP
decub
DIC
diff
dil
discontinued
discharge
dilatation and curretage
diet as tolerated
diastolic blood pressure
decubitus
disseminated intravascular coagulation
differential blood count
diluted
Page 3 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
DIP
DJD
DM
DNR/DNI
DOA
DOB
doe
DTR
DT
DT’s
DVT
Dx
distal interphlangeal
degenerative joint disease
diabetes mellitus
do not resuscitate/intubate
dead on arrival
date of birth
dyspnea on exertion
deep tendon reflexes
diptheria tetanus
delerium tremens
deep vein thrombosis
diagnosis
EAB
EBL
ECG
ECT
ED
EDC
EEG
EENT
EFM
EFW
e.g.
EKG
EMG
EMS
ENG
ENT
EOM
ER
ERCP
esp.
ESR
EST
et
ETOH
ETT
exam
exp
ext
elective abortion
estimated blood loss
electrocardigram
electroconvulsive threrapy
emergency department
estimated date of confinement
electroencephalogram
eye, ear, nose and throat
external fetal monitor
estimated fetal weight
for example
electrocardiogram
electromyogram
emergency medical device
electronystgmogram
ear, nose and throat
extraocular movement
emergency room
endoscopic retrograde cannulation of pancreatic duct
especially
erythrocyte sedimentation rate
electroshock therapy
and
ethyl alcohol; ethanol
endotracheal tube
examination
exploratory
extremities
F
FB
FBS
FDIU
Fe
FFP
Fahrenheit
foreign body
fasting blood sugar
fetal death in utero
Iron
fresh frozen plasma
Page 4 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
FHT
fib
fl;fld
ft.
FTA
f/u
FUO
Fx
fetal heart tones
fibula
fluid
foot
flourescent treponeal antibody
follow-up
fever of unknown origin
fracture
g
G
GA
GB
GC; Gc
GE
gen.
GERD
GGT
GI
GM; gm
GP
gr.
GSW
Gt; gt
Gtt; gtt
GTT
GU
Gyn
gram
gravida
general anesthesia
gallbladder
Gonococcus, gonorrhea
gastroesophogeal
general
gastroesophogeal reflux disease
gamma glutamyl transpeptidase
gastrointestinal
gram
General Practitioner
grain
gun shot wound
drop
drops
glucose tolerance test
genitourinary
Gynecology
H; h
HA
Hb.
HCM
HCT
HEENT
Hemi
Hep A
Hep B
Hep C
Hg
Hgb
HIV
H.O.
H/O
H&P
HR
hs
HTN
hour
headache
Hemoglobin
health care maintenance
hematocrit
head, eyes, ears, nose, and throat
hemiplegic
hepatitis A
hepatitis B
hepatitis C
mercury
hemoglobin
human immunodeficiency virus
House Officer
history of
history and physical
heart rate
at bedtime, hour of sleep
hypertension
Page 5 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
Hx
history
ICD
ICS
ICU
I&D
I&D
i.e.
IGA
IGM
IHSS
inf.
IM
IN
I&O
IOL
IOP
IP
IQ
IS
ITN
IUGR
IUP
IUPC
IV
IVP
intracardiac defibrillator
intercostal space
intensive care unit
incision and drainage
irrigation and drainage
that is
immunoglobulin A
immunoglobulin M
idiopathic hypertrophic subaortic stenosis
inferior
intramuscular
inches
intake and output
intra-ocular lens
intraocular pressure
interphalangeal
intelligence quotient
intercostal space
intrathecal narcotic
intrauterine growth retardation
intrauterine pregnancy
intrauterine pressure catheter
intravenous
intravenous pyelogram
JVP
jugular venous pressure
K
Kcal
KCl
kg
KUB
potassium
kilocalories
potassium chloride
kilogram
kidney, ureters, bladder
L
L&A
lab
Lac
LAD
lap
lat
LBW
LCL
LE
Li
lig
lumbar
light and accomodation
laboratory
laceration
left anterior descending
laparotomy/laparosocpy
lateral
low birth weight
lateral collateral ligament
lower extremity
Lithium
ligament
Page 6 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
lb
LBP
liq
LLL
LLQ
LMP
LNMP
LOC
LP
LS
LTC
LUL
LUQ
LVH
pound
low back pain
liquid
left lower lobe
left lower quadrant
last menstrual period
last normal menstrual period
level of consciousness
lumbar puncture
lumbosacral
long term care
left upper lobe
left upper quadrant
left ventricular hypertrophy
M; m
MA
MAT
MCA
mcg
MCL
MCP
mEq
mg
MI
MICU
MI-CD
ml
mm
mmgm
mod.
MR
MR
MRI
MS
MS
MS/MI
MSPN
MTP
MTX
M/V
MVR
meter
mental age
multifocal atrial tachycardia
motorcycle accident
microgram
medial collateral ligament
metacarpophalangeal
milliequivalent
milligram
myocardial infarction
medical intensive care unit
mentally ill and chemically dependent
milliliter
millimeter
millimicrogram
moderate
mentally retarded
mitral regurgitation
magnetic resonance imaging
multiple sclerosis
morphine sulfate
mitral valve stenosis/mitral valve insufficiency
Medical Student progress note
metatarsophalanageal
methotrexate
motor vehicle
mitral valve regurgitation
Na
NB
neg.
Neuro
NG
sodium
newborn
negative
neurology
nasogastric
Page 7 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
NH4
NKA
NKDA
no.
noc.
non rep
NPH
npo
NSR
NST
NSVD
ntg.
NWB
ammonium chloride
no known allergies
no known drug allergies
number
night
do not repeat
normopressure hydrocephalus
nothing by mouth
normal sinus rhythm
non-stress test
normal spontaneous vaginal delivery
Nitroglycerin
nonweight bearing
O2
OB
OBS
OCT
OD
OFC
OGTT
O.M.
omn..hoc.
omn.noc.
OPD
Opthth
OPV
OR
ORIF
Orth
os
O.S.
OT
oto
O.U.
oz.
oxygen
obstetrics
organic brain syndrome
oxytocin challenge test
right eye
occipitofrontal circumference
oral glucose tolerance test
otitis media
every hour
every night
out patient department
ophthalmology
oral polio vaccine
operating room
open reduction, internal fixation
orthopedics
by mouth
left eye
occupational therapy
otology
both eyes
Ounce
p
p
p
P-A
P&A
PACU
PAT
Path
pc
PCA
PCL
para
after
pulse
posterior/anterior
percussion and auscultation
post anesthesia recovery room
paroxysmal atrial tachycardia
pathology
after meals
patient controlled analgesia
posterior cruciate ligament
Page 8 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
PD
PDA
PE
Ped.
per
PERRLA
PH
PICU
PID
PIH
PIP
PKU
PM&R
PMS
PND
P.O.
POD
pp
PP
PPTL
PPD
PRBCs
pre-op
prep
PRIND
PRN
PROG
PROM
PROM
Psy.
pt.
PT
PTA
PTCA
PTSD
ptt.
PVCs
PWB
peritoneal dialysis
patent ductus arteriosis
physical examination
Pediatrics
by
Pupils Equal Round React to Light and Accomodation
past history
pediatric intensive care unit
pelvic inflammatory disease
pregnancy inducted hypertension
proximal interphalangeal
phenylketonuria
physical medicine and rehabilitation
prementrual syndrome
paroxysmal nocturnal dyspnea
by mouth
post operative day
post prandial
post partum
post partum tubal ligation
post partum day
packed red blood cells
pre-operative
preparation
partially reversed ischemic neurologic deficit
as needed, as necessary
prognosis
passive range of motion
premature rupture of membranes
Psychiatry
Patient
physical therapy
prior to admission
percutaneous transvenous coronary angioplasty
post traumatic stress disorder
partial thromboplastin time
premature ventricular contractions
partial weight bearing
q
qam
qd
qh
q 2h
qhs
qid
qns
qod
every
every morning
every day
every hour
every 2 hours
every night
four times a day
quantity not sufficient
every other day
Page 9 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
qs
qt.
Quad
quantity sufficient
quart
quadriplegie
R
RBC
RCA
RDS
Rehab
rep.
Rh
RLL
R/O
ROM
RR
RUL
RUQ
Rx
respiration
red blood cell
right coronary artery
respiratory distress syndrome
rehabilitation
let it be repeated
rhesus
right lower lobe
rule out
range of motion
respiratory rate
right upper lobe
right upper quadrant
treatment
s
S
SAB
SAH
SAO2
SBE
SBO
SBP
SCI
SDH
SDS
SGOT
SGPT
SGW
SI
SIADH
SICU
SIDS
SLE
SLR
SO
SOB
sol.
S/P
spec.
SPT
sp.gr.
sq
without
sacral
spontaneous abortion
subarachnoid hemorrhage
pulse oximetry O2 saturation
subacute bacterial endocarditis
small bowel obstruction
systolic blood pressure
spinal cord injury
subdural hematoma
same day surgery
serum glutamic oxalacetic transaminase
serum glutamic pyruvic transaminase
shotgun wound
sacrolliac
syndrome of inappropriate anti diuretic hormone
surgical intensive care unit
sudden infant death syndrome
systemic lupus erthematosus
straight leg raising
significant other
short of breath
Solution
status post
specimen
serum pregnancy test
specific gravity
subcutaneous
Page 10 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
Page 11 of 13
S&R
SROM
ss
SSS
Staph.
stat
STD
Strep.
STSG
sup.
Surg
sx
sym.
syr.
seclude and restrain
spontaneous rupture of membranes
half
sick sinus syndrome
Staphylococcus
at once, immediately
sexually transmitted disease
Streptococcus
split thickness skin graft
Superior
surgery
symptoms
Symptoms
Syrup
T
T&A
tab.
TAB
TACS
TAH
TB; tb
TBG
TBI
TBSA
TEE
temp.
TF
TIA
tid
tib
TKA
TM
TORCH
TORCHS
TPN
TPR
TR
Tx
T-spine
TSH
TTA
TTN
TUR
TURP
Type 1 DM
Type 2 DM
temperataure
tonsillectomy and adenoidectomy
Tablet
threatened abortion
trauma acute care surgery service
total abdominal hysterectomy
tuberculin
thyroid binding globulin
traumatic brain injury
total body surface area
transesophogeal echocardiogram
temperature
to follow
transient ischemic attack
three times a day
tibia
total knee arthroplasty
tympanic membrane
toxoplasmosis, rubella, cytomegalovirus, herpes simplex
toxoplasmosis, rubell, cytomegalovirus, herpes simplex, syphilis
total parenteral nutrition
temperature, pulse, respiration
time request
treatment
thoracic spine
thyroid stimulating hormone
trauma team activation
transitory tachypnea of newborn
transurethral resection
transurethral resection of prostate
insulin dependent diabetes mellitus
non-insulin dependent diabetes mellitus
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
UA
UC
UE
ung.
UPJ
URI
UPT
Urol.
UTI
urinalysis
urine culture
upper extremity
Ointment
ureteropelvic junction
upper respiratory infection
urine pregnancy test
Urology
urinary tract infection
vag.
VBAC
VCUG
VD
VHD
vol.%
V/Q scan
VS
VSD
Vagina
vaginal birth after cesarean
voiding cytourethrogram
venereal disease
valvular heart disease
volume percent
ventilation perfusion lung scan
vital signs
ventriculoseptal defect
WBC, wbc
w/c
WD
WN
WNL
WT, wt
w/v
white blood count
wheelchair
well-developed
well-nourished
within normal limits
weight
weight by volume
Y/O
year old
Page 12 of 13
WSCHS Clinical Manual
Category
Medical
Subject
Abbreviations
Page 13 of 13
Symbol Definition:
Effective
c-abbrev
1/00
Approval
Medical Director_____________________________
Executive Director____________________________