REFERENCE
CONTENTS
PAGE
Abbreviations ............................................................................................................................................. 396
Equivalents (Centigrade-Fahrenheit) ........................................................................................................ 401
Equivalents (Length).................................................................................................................................. 402
Kilogram-to-Pound Conversion Table ....................................................................................................... 403
Forms Index ............................................................................................................................................... 404
395
ABBREVIATIONS
The abbreviations in this list are common abbreviations used in medical record documentation and are not
meant to be inclusive. Abbreviations are to be approved for use in the facility by the Resident Care Policy
Committee and included in the Policy Manual. All staff are to be familiar with the approved list and limit
abbreviations in the medical record to this list. New abbreviations should not be used until approved.
A
abd
a.c.
ACTH
ad lib
AKA
a.m.
A.M.A.
ASCVD
abdomen
before meals
adrenocorticotrophic hormone
at discretion, as desired
also known as
morning
against medical advice
arteriosclerotic cardiovascular disease
B
b.i.d.
B.M.
B/P
BPH
BUN
twice a day
bowel movement
blood pressure
benign prostatic hypertrophy
blood urea nitrogen
C
c
C
CA
cal.
CAS
cath
CBC
CBS
cc
CC
CDC
CHF
cm
CNS
COPD
CO2
CSF
CV
CVA
cva
with
Centigrade
carcinoma
calorie
cerebroarteriosclerosis
catheter
complete blood count
chronic brain syndrome
cubic centimeter
chief complaint
Centers for Disease Control
congestive heart failure
centimeter
central nervous system
chronic obstructive pulmonary disease
carbon dioxide
cerebral spinal fluid
cardiovascular
cerebrovascular accident
costovertebral angle
D
DC
DM
DNR
DOA
discontinue
diabetes mellitus
do not resuscitate
dead on arrival
396
DOE
Dr.
DT
DTR
DX
dyspnea on exertion
doctor
delirium tremens
deep tendon reflexes
diagnosis
397
E
E. COLI
EEG
EKG (ECG)
elix.
EMG
ENT
EOM
eq.
ESR
Escherichia coli
electroencephalogram
electrocardiogram
elixir
electromyogram
ears, nose, throat
extraocular movements
equivalent
erythrocyte sedimentation rate
F
F
FBS
FDA
Fe
F. Hx
Fl.
FUO
Fx
Fahrenheit
fasting blood sugar
Food and Drug Administration
iron
family history
fluid
fever of undetermined origin
fracture
G
GC
GI
Gm
gr.
gtts.
GU
Gyn
gonorrhea
gastrointestinal
gram
grain
drops
genitourinary
gynecology
H
H2O
HBD
HBV
Hct.
HCVD
hgb
HHD
Hi-cal
HIV
hpf
Hs
Hx
water
had been drinking
Hepatitis B Virus
hematocrit
hypertensive cardiovascular disease
hemoglobin
hypertensive heart disease
high caloric
Human Immunosuppressant Virus
high-powered field
at bedtime
history of
I
I&D
I.D. Team
IM
incr.(inc.)
IPPB
IV
IVP
incision and drainage
Interdisciplinary team
intramuscular
increase
intermittent positive pressure breathing
intravenous
intravenous pyelogram
398
K
K
KUB
potassium
kidney, ureter, bladder (X-ray)
L
L
lab.
lat.
LE
Liq.
LLL
LLQ
LMP
lpf
LUL
LUOQ
LUQ
left
laboratory
lateral
lupus erythematosus
liquid
left lower lobe (of lung)
left lower quadrant
last menstrual period
low powered field
left upper lobe (of lung)
left upper outer quadrant
left upper quadrant
M
MDRTB
MDS
med.
mEq
mg
mg%
min.
ml
mm
MOM
mono.
MRSA
MS
Multiple drug resistent tuberculosis
Minimum Data Set
medication
milliequivalent
milligram
milligram percent
minute, minimum, minim
milliliter
millimeters
milk of magnesia
monocyte
Methicillin Resistent Staphylococcus Aureus
multiple sclerosis
N
Na
N/A
neg.
nil
noct./NOC
NPO
N/S
sodium
not applicable
negative
none
night
nothing by mouth
normal saline
O
O2
OD
ortho
OS
O.T.
OU
oz.
oxygen
right eye
orthopedic
left eye
occupational therapy
both eyes
ounce
P
P
pulse
399
PA
P.A.
PAT
p.c.
PE/Px
PERRLA
pH
P Hx
PI
PID
p.m.
PMI
PND
p.o.
P.O.
pp
p.r.
prn
P.T.
pt.
PVC
posteroanterior
physician’s assistant
paroxysmal atrial tachycardia
after meals
physical examination
pupils are equal, regular, react to light and accommodation
hydrogen ion concentration
past history
present illness
pelvic inflammatory disease
evening
point of maximum impulse (impact)
post-nasal drip
telephone order
by mouth
postprandial (after meals)
per rectum
when needed
physical therapy
patient
premature ventricular contractions
Q
q.d.
q.h.
q.i.d.
q.n., q.noc.
q.o.d.
q.s.
qt.
every day
every hour
four times a day
every night
every other day
quantity sufficient
quart
R
R
(R)
RAI
RAP
RBBB
rbc
RLL
RLQ
R/O
RRE
R.T.
RUL
RUOQ
RUQ
Rx
right
rectal
Resident Assessment Instrument
Resident Assessment Protocol
right bundle branch block
red blood cells
right lower lobe
right lower quadrant
rule out
round, regular, equal
Respiratory therapy
right upper lobe
right upper outer quadrant
right upper quadrant
drug therapy
S
s
SGOT
SGPT
SOB
without
serum glutamic oxaloacetic transaminase
serum glutamic pyruvic transaminase
short of breath
400
ss
SSE
S.T.
stat
sub. ling.
subq.
staph
strep
STS
half
soap suds enema
speech therapy
immediately and only once
sublingually
subcutaneously
staphylococcus
streptococcus
serologic test for syphilis
T
tab
Tbc-T.B.
t.i.d.
tinc.
T.O.
TPR
Tx
tablet
tuberculosis
three times a day
tincture
telephone order
temperature, pulse, respiration
treatment
U
u
ung.
URI
UTI
unit
unguent
upper respiratory infection
urinary tract infection
V
vag.
VC
VD
VDRL
vit.
vol.
vol.%
vaginally
vital capacity
venereal disease
venereal disease research laboratory (test)
vitamin
volume
volume percent
W
wbc
WD
wk
WN
wt.
white blood count
well developed
week
well nourished
weight
Y
yr
year
NOTE: The use of symbols for ounce, dram, degree, increase, decrease, male, female, and all others are
discouraged due to the use of the metric system and computer reproduction.
401
EQUIVALENTS (CENTIGRADE-FAHRENHEIT)
To convert Centigrade to Fahrenheit, multiply C by 9/5 and add 32.
To convert Fahrenheit to Centigrade, subtract 32 from F and multiply by 5/9.
402
EQUIVALENTS (LENGTH)
INCHES
01
02
04
06
08
12 = 1 foot
18
24
30
36 = 1 yard
39.4
CENTIMETERS
002.54
005.1
010.2
015.2
020.3
030.5
046
061
776
091
100 = 1 meter
CENTIMETERS
001
002
003
004
005
006
008
010
020
030
040
050
060
070
080
090
100
INCHES
00.4
00.8
01.2
01.6
02.0
02.4
03.1
03.9
07.9
11.8
15.7
19.7
23.6
27.6
31.5
35.4 = approx.
1 yard
39.4
403
KILOGRAMS TO POUNDS
CONVERSION TABLE
KILOGRAMS
44.5
44.9
45.4
45.8
46.3
46.7
47.2
47.6
48.1
48.6
49.0
49.5
50.0
50.4
50.8
51.3
51.8
52.2
52.7
53.1
53.6
54.0
54.5
54.9
55.3
55.8
56.3
56.7
57.2
57.6
58.1
58.5
59.0
59.5
59.9
404
POUNDS
098
099
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
KILOGRAMS
60.3
60.6
61.3
61.7
62.2
62.7
63.1
63.6
64.0
64.4
64.9
65.3
65.8
66.3
66.8
67.2
67.6
68.1
68.6
69.1
69.6
70.0
70.5
70.9
71.4
71.8
72.3
72.7
73.2
73.6
74.1
74.6
75.0
75.4
75.8
POUNDS
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
KILOGRAMS
76.3
76.8
77.3
77.7
78.1
78.8
79.1
79.6
80.0
80.5
80.9
81.4
81.8
82.2
82.7
83.1
83.6
84.0
84.7
85.0
85.4
85.9
86.3
86.6
87.1
87.7
88.1
88.6
89.0
89.5
90.0
90.4
90.9
POUNDS
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
FORMS INDEX
RELATED PROCEDURE
FORM
TITLE OF FORM
Resident Rights Policy
CFS1-5/2
Consent to Release Medical ................................ 11
Information
Consent to Participate in ....................................... 13
Experimental Research
CFS1-7/3P(TP)
PAGE
Resident Assessment Policy
CFS2-2/2P(TP)
Post-Discharge Plan of Care ................................ 40
Admission of the Resident
CFS6-1HH(HF)
ADL Functional/Restorative ................................ 124
Assessment and Progress
Physician’s Telephone Orders ........................... 128
Audit
Admission Nursing Assessment ........................ 128
Initial Activity Assessment .................................. 128
Initial Social Service History ............................... 128
Social Services Assessment ............................... 129
Initial Nutritional History/ ..................................... 129
Assessment Data Collection Form
Malnutrition Risk Assessment ............................. 129
1393/3
CFS5-3HH(HF)
CFS4-1/2P(TP)
CFS4-10HH(HF)
CFS4-12HH(HF)
CFS5-5HH(HF)
CFS6-20HH(HF)
AMA Release
3022R
Release from Responsibility for ......................... 134
Discharge
A.M. Care
3318
3315
Nursing Assignment Sheet ................................. 145
Assignment Sheet ............................................... 145
Bath (Bed)
3195
Patient’s Bath Record ......................................... 170
Bladder Management
(Retraining) Program
CFS6-10HH(HF)
CFS6-11HH(HF)
635
Bladder Retraining Assessment ......................... 196
Bladder Retraining Record ................................. 196
Assessment for B & B Training ........................... 196
Bowel Management
(Retraining) Program
CFS6-8HH(HF)
CFS6-9HH(HF)
Bowel Retraining Assessment ............................ 207
Bowel Retraining Record .................................... 207
Diabetes Mellitus, Guidelines for CFS6-22HH(HF)
Diabetic Monitoring Flowsheet ............................ 250
Discharge/Transfer of the ResidentCFS2-4/2P(TP)
CFS2-2/2P(TP)
Resident Transfer Form ...................................... 257
Post-Discharge Plan of Care .............................. 257
Drug Order Procedure
3107
Drug Order Sheet................................................ 267
Enteral Nutritional Therapy
(Tube Feeding)
CFS6-15HH(HF)
CFS6-16HH(HF)
Enteral Fluids Flowsheet .................................... 288
Enteral Feeding Record ...................................... 288
Incident/Accident/Medication
Error Report
CIS6-18120
CFS6-30
Incident/Accident Report ..................................... 346
Medication Error Report ...................................... 346
Intake and Output Measurement 3054/2S
1012
Intake & Output Record ...................................... 360
Intake & Output Record ...................................... 360
Inventory List
Inventory List ...................................................... 371
Inventory of Personal Effects .............................. 371
883/2
CFS1-12/2P(TP)
405
Narcotic Count
113
Daily Narcotic Record Sheet ............................... 384
Pass Procedure
3027
Release of Responsibility for Leave of .............. 411
Absence
RELATED PROCEDURE
FORM
TITLE OF FORM
Positioning the Resident
1300
Bed Patient Turn Record .................................... 428
Post-Mortem Care
296
Record of Death .................................................. 431
Pressure Ulcer, Care and
Prevention Of
3166P
3167P
Braden-Scale Pressure Sore .............................. 437
Risk Assessment
Norton Plus Pressure Ulcer Scale ...................... 437
Psychotropic (Psychoactive)
Drug Documentation
L-2990
L-2991
L-2992
L-2993
L-2294
Anti-Psychotic Label ........................................... 440
Anti-Anxiety Label ............................................... 440
Sedative/Tranquilizer Label ................................ 440
Anti-Depressant Label ........................................ 440
Hypnotic/Benzodiazepines Label ........................ 440
Range of Motion
CFS6-12HH(HF)
Range of Motion Assessment ............................. 447
PAGE
Release Against Medical Advice 3022R
Release from Responsibility for ......................... 457
Discharge
Release of Side (Bed) Rails
3023
Release of Side Rails ......................................... 460
Report (Guidelines for
Nursing Report)
488
253R
Daily Log ............................................................. 463
Day/Night Report ................................................ 463
Resident Assessment
(Comprehensive Assessment)
1728RHH(HF)
Minimum Data Set (MDS) 2.0 ............................. 468
Resident Care Plan
3269HH(HF)
CFS5-12HH(HF)
Resident Care Plan ............................................. 475
Interdisciplinary Care Plan .................................. 475
Restraints (Physical)
CFS3-1HH(HF)
CFS3-2HH(HF)
Pre-Restraining Assessment .............................. 480
Physical Restraint Elimination ........................... 481
Assessment
Restraint Release Record ................................... 481
CFS3-3HH(HF)
Telephone Order Processing
3245(P)
1393/3
Telephone Orders Mount Sheet .......................... 519
Physician’s Telephone Orders ........................... 519
Audit
Temperature, Pulse and
Respirations
3051
CFS6-21HH(HF)
Vital Signs .......................................................... 523
Vital Signs and Weight Record ........................... 523
Tuberculin Test (Mantoux)
2121HH(HF)
2122
Tuberculosis Surveillance .................................. 554
Summary Record
Monthly Schedule for TB Testing ........................ 554
CFS6-18/2
Incident/Accident Report ..................................... 562
Unusual Occurrence Report
406
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407