COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
Policy Title:
Columbus County Health Department (CCHD) Accepted Abbreviation
Listing Policy and Procedures
Program Area:
Policy Identifier:
(optional)
Effective Date:
Revision
Date(s):
Approved by:
Kim Smith RN, BSN, MSHCA, Health Director
Approved by:
Hilda Memory RN, BS, MSHA, Director of Nursing
1/2000,
11/2001, 4/28/2015, 1/22/2016
Purpose:
To standardize terminology used in the patient’s clinical records
Definitions:
CCHD staff members use only abbreviations approved by the Health Department in documenting
in clinical records. These accepted abbreviations will b review and revised periodically.
Responsibilities:
All CCHD Staff
Procedures:
The list of abbreviations is used by all CCHD staff when documenting in
clinical records.
AC- before meals
AAA- abdominal aortic aneurysm
A&SE- action and side effects
Ab- antibody
abd- abdominal/abdomen
ac -before a meal
ADA -American Diabetic Association
ADHD- attention deficit-hyperactivity disorder
ADL- activities of daily living
ad lib. - As desired
Admin. - Administration
AFB- acid-fast bacillus
AFP -alpha-fetoprotein
Administration Revised 1/22//2016
Page 1 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
Ag- antigen
A/G- albumin/globulin ratio
AIDS- acquired immunodeficiency syndrome
AK- above the knee
Alb- albumin
AM- morning
A.M.- Annual Medical
A.M.A.- against medical advice
Amb.- ambulation
ANA- antinuclear antibody
ANS- Autonomic nervous System
ant. - Anterior
AP -Apical Pulse
approp. -Appropriate
A-P -anterior-posterior
A&P- auscultation and percussion
appt. - Appointment
ARC- AIDS-related complex
ARDS- acute respiratory distress syndrome
AS- left ear
ASA- acetylsalicylic acid
ASC- atypical squamous cells
ASCVD- Arteriosclerotic cardiovascular disease
ASC-US- atypical squamous cells of undetermined significance
Assignment of Benefits- Ass. Of Bene.
AU- both ears
AV - atrio-ventricular
Baldwin Woods OBG/GYN- BWOBGYN
B/B- Bowel and Bladder
BC/BS -Blue Cross Blue Shield
BCCCP- Breast Cancer Cervical Cancer Program
BCLS -basic cardiac life support
BCP- birth control pills
bid -twice a day
bil. Bilateral
BKA -Below the knee amputation
bil.LE -both lower extremities
BK- below the knee
BLS- basic life support
Administration Revised 1/22//2016
Page 2 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
BLT- bilateral tubal ligation
BM- bowel movement
BMI- body mass index
BP- blood pressure
BMR- basal metabolic rate
BPH -benign prostatic hyperplasia
bpm- beats per minute
BRP- bathroom privileges
BS- blood sugar
BSE- breast self-examination
BUM -Back up method
BUN- blood urea nitrogen
BV- bacterial vaginitis
BW- body weight
Bx- biopsy
ca. cancer
CBC- complete blood count
CBI -continuous bladder irrigation
CC -chief complaint
CCU- critical care unit
CCHD- Columbus County Health Department
CD4- T-helper cells
CD8 -cytotoxic cells
CDC -Centers for Disease Control and Prevention
CG Care giver
CHF -congestive heart failure
CHO- carbohydrate
CIN- cervical intraepithelial neoplasia
CIS -carcinoma in situ
CK creatine kinase
cm- centimeter
CMP -comprehensive metabolic panel
CMT- cervical motion tenderness
CMV –cytomegalovirus
CNM- Certified Nurse Midwife
CNS- central nervous system
C&S -culture and sensitivity
c/o- complains of
Colp -Colposcopy
Columbus Regional- Col. Reg.
Administration Revised 1/22//2016
Page 3 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
Columbus Regional Healthcare System- CRHS
comp.- comprehension
cont.- continue
COPD -chronic obstructive pulmonary disease
CP- cerebral palsy; cleft palate
CPAP -continuous positive airway pressure
CPD- cephalopelvic disproportion
CPK -creatine phosphokinase
CPR- cardiopulmonary resuscitation
CRP- c. reactive protein
CS -cesarean section;
CT -computed/computerized tomography
CTA- clear to auscultation
Cult.- Culture
CV -cardiovascular
CVD -cardiovascular Disease
CVA- cardiovascular accident
Cx - Cervical
CXR -chest x-ray
D- divorced
D and C dilatation and curettage
dB- decibel
DBP- diastolic blood pressure
dc- discontinue
DIC- disseminated intravascular coagulation
diff - difficulty
dil. –dilute
Disclosure of Information- Dis. Of Info.
dgt -daughter
DJD -degenerative joint disease
DKA- diabetic ketoacidosis
dL- deciliter
DM -diabetes mellitus
DNR -do not resuscitate
DOB- date of birth
DOD-Date of delivery
DON- Director of Nursing
DOS- Date of Service
DPT- diphtheria-pertussis-tetanus (vaccine)
Dr. - Doctor
Administration Revised 1/22//2016
Page 4 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
Dr. Signature- Dr. Sig.
DSS- Department of Social Services
DT -Diptheria tetanus
DTP -Diptheria, tetanus, and pertussis
DUB- dysfunctional uterine bleeding
DVT -deep vein thrombosis
Dx –diagnosis
EBV -Epstein-Barr virus
EDD- estimated date of delivery (formerly EDC: estimated date of confinement)
EENT -eye, ear, nose, and throat
EIA- enzyme immunosorbent assay
ELISA e-nzyme-linked immunosorbent assay
EMR- Electronic Medical Record
ENT -ear, nose, and throat
EP -extrapyramidal
ER- Emergency Room, extended-release
ERRN- enhanced role registered nurse
ESR -erythrocyte sedimentation rate
ESRD -end-stage renal disease
etc.- etcetera
ETOH,0 ethyl alcohol
eval.- evaluation
ex.- Example
ext.- extension
f- female
FBS- fasting blood sugar
Fe- iron
FHT- fetal heart tone
FI- Food Instruments
FP- Family Planning
FNP -Family nurse practitioner
FSH- follicle-stimulating hormone
FTT -failure to thrive
F/U- Follow Up
FUO -fever of unknown origin
g/d- Grams per day
GB- gallbladder; Guillain-Barré
GC- gonorrhea culture
GDM -gestational diabetes mellitus
GERD- gastroesophageal reflux disease
Administration Revised 1/22//2016
Page 5 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
GH -growth hormone
GI- gastrointestinal
glu- glucose
gm- gram
GND- gram negative diplococci
GNED- gram negative extracellular diplococci
GNID- gram negative intracellular diplococci
GNR- gram negative rods
GP- general practitioner
GPN- gram positive rods
GSW- gunshot wound
GTT- glucose tolerance test
gtt- drops
GU genitourinary
GYN –gynecology
hr- hour
H&H- Hematocrit and hemoglobin
HA- headache
HAV- hepatitis A virus
HBV- hepatitis B virus
HCG- human chorionic gonadotropin
Hct.- Hematocrit
HCV- hepatitis C virus
HD- Health Director
HDL -high-density lipoprotein
HEADSS- Home Environment, Education, and Employment, Activities, Drugs,
Sexuality, Suicide/Depression.
HEPA high–efficiency particulate air
Hg -mercury
hgb –hemoglobin
HGSIL- high-grade squamous intraepithelial lesion
H&P – History and Physical
Hib- Haemophilus influenzae type B
HIPAA- Health Information Portability and Accountability Act
HIV- human immunodeficiency virus
h/o- history of
H2O -water
H2O2- -hydrogen peroxide
h.s. bedtime
HPI -history of present illness
Administration Revised 1/22//2016
Page 6 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
HPV- human Papillomavirus
HR-heart rate
HRT- hormone replacement therapy
HSIL- high-grade squamous intraepithelial lesion
HSV- herpes simplex virus
Ht.- height
HTN- hypertension
HV- home visit
hx – history
Hypo- hypodermic
I&O -intake and output
IBW- ideal body weight
IBS- Irritable Bowel Syndrome
IBW-Ideal body weight
ICU- intensive care unit
I & D – incision and drainage
IDDM -insulin-dependent diabetes mellitus
ie.- for example
Ig- immunoglobulin
IgE- immunoglobulin E
IM –intramuscular
INH- Isoniazid
inj.- injection
instill. -instillation
I&O- intake and output
IQ- intelligence quotient
IR- internal rotation
irreg.- irregular
I.U. a- international unit
IUD- intrauterine device
IUFD -intrauterine fetal death
IURG- intrauterine growth retardation
K+ -potassium
Kcal/d- Kilocalories per day
kg -kilogram
KS- Kaposi sarcoma
KUB- kidney, ureter, and bladder
L&D -labor and delivery
lab- laboratory
Administration Revised 1/22//2016
Page 7 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
lb.- pound
LBW- low birth weight
L&D- labor and deliver
LDL- low-density lipoprotein
LE- lower extremity
LEEP loop electrosurgical excision procedure
LFT- liver function test
LGA -large for gestational age
LGM-left gluteus maximus
LH -luteinizing hormone
liq.- liquid; fluid
LL- lower leg
LLB- long leg brace
LLE -left lower extremity
LLL- left lower lobe
LLQ -left lower quadrant
LMP- last menstrual period
LNMP- last normal menstrual period
LPN- licensed practical nurse
LOC- level/loss of consciousness
LS – lumbar sacral
LSIL- low-grade squamous epithelial lesion
LUQ- left upper quadrant
M- Male
m- minims
mat.- maternal
Maternal Consent- MAT. Consent
Maternal Health- MH
M-caid – Medicaid
M-Care- Medicare
mcg- microgram
MCHAT- Modified Checklist for Autism in Toddlers-Revised)
Med-solution Approval- Med Sol. App.
Med SW- medical social work
Meds.- medication
Message- mess.
MD- muscular dystrophy
MG -myasthenia gravis
Mg- magnesium
MgSO4- magnesium sulfate
Administration Revised 1/22//2016
Page 8 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
µg- microgram
mg- milligram
MGF- maternal grandfather
MGM- maternal grandmother
Micro- microscope
Missed Appointment- Miss. Appt.
ml- milliliter
mm Hg- millimeters of mercury
MMR- measles-mumps-rubella (vaccine)
Mn- manganese
MNT- Medical Nutritional Therapy
mod. – moderate
MR- mental retardation or method return
MRA- magnetic resonance angiography
MRI -magnetic resonance imaging
M.S. – Master of Science degree
MSW- Mater of Social Work
MVA -motor vehicle accident
NA- native American
N.A- nursing assistanct
N/A- not applicable
Na- sodium
NaCL- sodium chloride
NAD- no acute distress
Neg.- negative
NF- Not found
NG - nasogastric
NGT- nasogastric tube
NICU -neonatal intensive care unit
NIDDM- noninsulin-dependent diabetes mellitus
NIH- National Institutes of Health
NKA- no known allergies
NKDA- no known drug allergies
NP- Nurse Practitioner
NPO- nothing by mouth
NS -normal saline
NSAID- nonsteroidal anti-inflammatory drug
Nsg - nursing
NSR -normal sinus rhythm
NST- non-stress test
Administration Revised 1/22//2016
Page 9 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
Nutr- nutritionist
N&V- nausea and vomiting
NVD- normal vaginal delivery
NWB- non-weight bearing
O2 oxygen
OB –obstetrics
OBCM- Obstetrical Case Manager
OC- oral contraceptive
Occ. – occasionally
OCD -obsessive-compulsive disorder
O.D.- right eye
Oint.- ointment
OM- Otitis media
OOB- out of bed
O.S.- left eye
O T occupational therapy
OU- each eye
oz-ounce
P- Pulse
PAD- peripheral arterial disease
PAP test- Papanicolaou smear
Para- produced offspring-pregnancy
pat- paternal
p.c.- after meals
PCC- Patient Care Coordinator
PCM- Pregnancy Care Manager
PCOS -polycystic ovarian syndrome
PCP - primary care provider
PE- physical examination
PEARL pupils equal, round, react to light and accommodation
Ped.- Pediatric
PMD- Primary Medical Doctor
per- through or by
PET- positron emission tomography
PFT -pulmonary function test
PGF- Paternal grandfather
PHN- Public Health Nurse
PI -present illness
PID -pelvic inflammatory disease
PIH- pregnancy-induced hypertension
Administration Revised 1/22//2016
Page 10 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
Pkg- package
PKU -phenylketonuria
PM -afternoon/evening
PMH- past medical history
PMI- point of maximal impulse
PMS -premenstrual syndrome
PN- Prenatal
p.o. orally-by mouth
Pos.- Positive
Post. Op- post operative
Pp -placenta previa
PP- Postpartum
2hr. PPBS – 2 hour post prandial blood sugar
PPD- purified protein derivative (TB test)
Preg- pregnancy
Prev.- Previous
Presumptive Eligibility- Pre. Elig.
p.r.n.- as needed
PRO- Protein
POI- Proof of income
PSA- prostate-specific antigen
PT- prothrombin time
PTL- preterm labor
Pt - patient
P.T.- Physical Therapy
PTT- partial thromboplastin time
PVD- Peripheral Vascular Disease
PZA- Pyrazinamide
q- every
q am- every morning
q.d. -every day
q.h.- every hour
q.2h. -every 2 hours
q.3h. -every 3 hours
q.4h. -every 4 hours
q.i.d. - four times a day
q. qt- quart
quad- quadriplegic
QA- Quality Assurance
QI- Quality Improvement
Administration Revised 1/22//2016
Page 11 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
R- Respiration
RA- rheumatoid arthritis
RBS- random blood sugar
RBC-red blood count
RDA- recommended daily/dietary allowance
RDN- registered dietician nutritionist
Re:- regarding
Reschedule- Resc.
RLL- right lower lobe
RLQ -right lower quadrant
RN- Registered Nurse
RNA- ribonucleic acid
R/O- rule out
ROM- range of motion
ROS- review of systems
RSV- respiratory syncytial virus
RT- respiratory therapy
R/T- related to
Rt. - right
RUE -right upper extremity
RUL- right upper lobe
RUQ -right upper quadrant
Rx.- prescription
SAB- spontaneous abortion
SAD- seasonal affective disorder
SBE- self breast exam
Sed rate- sedimentation rate
SGA- small for gestational age
SIDS -sudden infant death syndrome
SLP- speech-language pathology
SNAP -Special Nutrition Assistance Program
SOAP -Subjective-Objective-Assessment-Plan
SOB- shortness of breath
sp gr- specific gravity
s.q. -subcutaneous(ly)
SROM- spontaneous rupture of membranes
ss or 1/2- a half
S/S- signs and symptoms
Staph -Staphylococcus
Administration Revised 1/22//2016
Page 12 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
stat.- immediately
STD -sexually transmitted disease
STI’s- sexually transmitted infections
Strep -Streptococcus
ST- Speech therapy
STAT- immediately at once
STE- self – testicular exam
SW- Social Worker
Sx -symptoms
T- temperature
T4- throxine
TAB -therapeutic abortion
TAH- total abdominal hysterectomy
TB –tuberculosis
t/c- Telephone Call
THR- total hip replacement
TIA -transient ischemic attack
TIBC- total iron-binding capacity
t.i.d.- three times a day
TKR- total knee replacement
TM -tympanic membrane
TMJ- temporomandibular joint
TNTM-too numerous to mention
TPI -Treponema pallidum immobilization test for syphilis
TPR -temperature, pulse, and respiration
Tric- Trichomonas
TSE- testicular self-examination
TSH- Thyroid stimulating hormone
tsp.- teaspoon
TSH- thyroid-stimulating hormone
Tx- treatment
U- Unit
UA- urinalysis
UA& C&S- urinalysis and culture and sensitivity
U/C- Uterine contractions
UE- Upper extremity
Umbil-umbilicus
URI- upper respiratory infection
US - ultrasound
Administration Revised 1/22//2016
Page 13 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
UTI -urinary tract infection
UV- ultraviolet
VBAC- vaginal birth after delivery
VD- venereal disease
VDRL- Venereal Disease Research Laboratories
VF- ventricular fibrillation
Vit.- vitamin
VLBW- very low birth weight
VLDL- very low density lipoprotein
V.O.- voiced order
Voc. Rehab.- vocational rehabilitation
vol. –volume
VS -vital signs
W- white
WBC- white blood cell; white blood count
WC- wheel chair
Wd.- wound
WDWN- well-developed, well-nourished
WF/BF- white female/black female
WIC- Special Supplemental Program for Women, Infants and Children
Wilmington Maternal Fetal Medicine- WMFM
Wk- week
WM/BM- white male/black male
WN- well-nourished
WNL- within normal limits
wt.-weight
y.o.- years old
yr- year
@- at
&- and
>- greater than
<- less than
= equal to
+ Positive results
ɵ-Negative results
∆- Change
♀ - female
♂ male
° Degree sign (example 1° 2° 3° etc.)
Administration Revised 1/22//2016
Page 14 of 15
COLUMBUS COUNTY HEALTH DEPARTMENTS
ACCEPTED ABBREVIATIONS POLICY
Care Coordination for Children and Pregnancy Care Managers utilize the
Community Care of North Carolinas (CCNC) Case Management Information System
(CMIS) for documentation. See listing of CMIS approved abbreviations attached.
CMIS Abbreviations
Dental Clinic utilize Health Information System (HIS) for their patient
documentation. See attached list of approved abbreviations for the dental clinc.
Dental Clinic Abbreviations
Laws and Rules:
Reference(s):
Tabers Dictionary of Medical Terminology
Administration Revised 1/22//2016
Page 15 of 15