14.10ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING
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PURPOSE:To provide a standardized method of uniform documentation in the health record to promote effective communication throughout the agency and for other healthcare providers.
PROCEDURE:
Note:Many of the attached abbreviations are not appropriate for use in the electronic record. Staff should not use symbolic abbreviations (ex., parentheses (), semi-colon ; or quotes “ ”)in Horizon HomeCare EHR.
- Whenever information is placed within the record and a symbol or abbreviation is utilized, staff must use only those abbreviations and symbols that have been approvedas accepted.
Effective Date:July 1994
Review Date:July 1999, August 2001, March 2003, September 2005, December 2006, June 2010
Revision Date:July 1995, June 1996, June 1997, July 1998, September 1999, September 2000, July 2004, February 2007, April 2007, June 2007, December 2008, September 2011, June 2012, October 2012, December 2013
Reviewed By:Kathryn Albritton, RHIA; Director of Professional Support Services
Meta Michelle Weeks, Nurse Mentor/PI Analyst; Sandra Pate RN BSN CRNI®, Education Manager
Approved by:
VP of Clinical ServicesDate
3HC
ACCEPTABLE INITIALS, ABBREVIATIONS, AND SYMBOLS FOR CHARTING
Unapproved AbbreviationsAccepted Changes
- qd daily
- cc ml
- MS morphine
- MSOmorphine
- u unit
- IU international unit
- MgSOmagnesium
- QODevery other day
- X.0 mgXmg
- .X mg0.Xmg
- A.U.both ears
- µg mcg
30 SEC STS / 30 SECOND SIT TO STAND TEST
3HC / Home Health and Hospice Care, Inc.
6MWD / 6 MINUTE WALK DISTANCE
6MWT / 6 MINUTE WALK TEST
A/O / Alert and oriented
A/SE / actions and side effects
A/T / assess and teach
ABC SCALE / ACTIVITY-SPECIFIC BALANCE CONFIDENCE SCALE
ABD / abdomen,
ABD / ABDUCTION (PT)
ABG / arterial blood gas
AD / assistive device
ADA / American Diabetic Association
ADD / ADDUCTION
ADL / activities of daily living
adm / admitted
admin / administered
AFB / acid-fast bacillus
AFO / ankle foot orthosis
AFP / Alphafetoprotein
AIDS / Acquired Immunodeficiency Syndrome
AIMS / abnormal involuntary movements
AKA / above-the-knee (amputation)
ALS / Amyotrophic Lateral Sclerosis;
AM / morning
AMA / against medical advice
amb / ambulate
AML / Acute Myelocytic Leukemia
amt / amount
ant / anterior
AP / apical pulse
AP / ankle pumps (PT)
approx / approximately
appt / appointment
APS / Adult Protective Services
AROM / active range of motion
ASA / aspirin
ASCVD / arteriosclerotic cardiovascular disease
ASD / arterial septal defect
ASHD / atherosclerotic heart disease
asst / assistance
aud / auditory
ausc / auscultation
AV / atrioventricular
ax / axillary
B&B / bowel and bladder
B/T / between
BBS / bilateral breath sounds
BBT / basal body temperature
BCBS / Blue Cross/Blue Shield
BCP / birth control pills
BDF / bilateral dorsi-flexion
BE / barium enema
BGM / blood glucose monitor
bili / bilirubin
BJH / Betsy Johnson Hospital
BKA / below-the-knee (amputation)
bld / blood
BLE / both lower extremities
BM / bowel movement
BMR / basal metabolic rate
BP / blood pressure
BPH / benign prostatic hypertrophy
BR / bedrest
BRP / bathroom privileges
BS / bowel sounds, breath sounds, blood sugar
BSC / bedside commode
BSN / Bachelor of Science in Nursing
BSW / Bachelor of Social Work
BTL / bilateral tubal ligation
BUE / bilateral upper extremities
BUN / blood urea nitrogen
BX / biopsy
C / Centigrade, Celsius
C&S / culture and sensitivity
C.C. / chief complaint
c/o / complain of
C1, C2, C3, etc. / first cervical vertebra, second cervical, etc.
CA / cancer, carcinoma
Ca / calcium, cancer
CABG / Coronary artery bypass graft
CAP/C / Community Alternatives Program for Children
CAP/DA / Community Alternatives Program for Disabled Adults
CAP/MR / Community Alternatives Program for the Mentally Retarded
CATH / catheter, catheterize
CBC / complete blood count
CBG / capillary blood glucose
CBS / chronic brain syndrome
CCU / Coronary Care Unit
CD / Clinical Director
CDC / Center for Disease Control, Child Development Center
CF / cystic fibrosis
CG / caregiver
CGA / contact guard assist
CHD / coronary heart disease
CHEM 12 / sequential multiple analysis of 12 chemistry constituents
CHEM 7 / sequential multiple analyzer with compound
chemo / chemotherapy
CHF / congestive heart failure
chr / chronic
CK / check
Cl / chloride
CLOF / current level of function
cm / centimeter
CM / Case Manager
CMS / Center for Medicare and Medicaid Services
CMV / cytomegalovirus
CNS / central nervous system
CO2 / carbon dioxide
comp. / comprehension
cont / continue
conv. / conversation
coord. / coordination
COPD / chronic obstructive pulmonary disease
COTA/L / Certified Occupational Therapy Assistant/Licensed
CP / cardiopulmonary
CP / cerebral palsy
CPAP / Continuous positive airway pressure
CPM / Continuous passive motion
CPR / cardiopulmonary resuscitation
creat / creatinine
C-sect / Cesarean section
CSF / cerebrospinal fluid
CT or CT scan / computerized axial tomography scan
CVA / cerebrovascular accident
CVD / cardiovascular disease
CXR / chest x-ray
cysto / cystoscopy
D / dependent
D&C / dilatation and curettage
D&E / dilatation and evacuation
D/C / discharge, discontinue
D/T / due to
D5W / 5% dextrose in water
DAUG / daughter
DEC / Developmental Evaluation Clinic
DEMO / demonstrate
DEMOS / demonstrations
DF / dorsiflexion
DGI: / DYNAMIC GAIT INDEX TEST
diff / differential
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
doc / document
DOE / dyspnea on exertion
DPT / diphtheria, pertussis, tetanus
Dr. / doctor
DRG / diagnostic-related-group
DSD / dry sterile dressing
dsg / dressing
DSS / Department of Social Services
DTR / deep tendon reflex
dtr (lowercase) / daughter
DTs / delirium tremens
DVT / deep venous thrombosis
dx / diagnosis
dz / disease
E. coli / Escheria Coli
e.g. / for example
E/SE / effect and side effects
ea / each
ECG, EKG / electrocardiogram
ED / emergency department
EDU / education
EEG / electroencephalogram
EENT / eye, ear, nose and throat
ELIM / elimination
elix / elixir
EMER / emergency
EMS / emergency medical services
ENG / English
ENT / ear, nose and throat
ENVIR / environment
EOB / edge of bed
EOM / extraocular movement
eos / eosinophil
EP / epidural
EQUIPM / equipment
ER / emergency room
ER / external rotation (PT)
esp / especially
ESRD / end-stage renal disease
et / and
etc. / and so on
etiol / etiology
ETOH / ethyl alcohol
ETS / Endo Tracheal Suction
eval / evaluation
EX’S / exercises
EXAC / exacerbations
exam / examination
exp / expressive
expir / expiration, expiratory
explap / exploratory laparotomy
Ext / extension
ext./EXT / external
F / Fahrenheit
F/U / follow-up
FBS / fasting blood sugar
FC / Foley catheter
FDA / Food and Drug Administration
Fe / iron
FFST: / FIVE TIME SIT TO STAND TEST
FHR / fetal heart rate
FHT / fetal heart tones
FICSIT / Fraility And Injuries: Cooperative Studies Of Intervention Techniques (Tests Of Progressive Static Balance)
fl. oz / fluid ounce
fld / fluid
Flex / Flexion
FMLA / Family Medical Leave Act
FNP / Family Nurse Practitioner
FOB / foot of bed
Freq. / frequency
FSBS / finger stick blood sugar
ft / foot, feet
FUO / fever of unknown origin
FWB / full weight bearing
Fx., fract. / fracture
gal / gallon
GDAU / granddaughter
GI / gastrointestinal
Gm, gm / gram
GT / gait
GT/TR / gait training
GTT / glucose tolerance test
G-Tube/GT / gastrostomy tube
GU / genitourinary
gyn / gynecology
H&H / hemoglobin and hematocrit
H&P / history and physical
H/O / history of
H2O / water
H2O2 / hydrogen peroxide
HA / headache
HB, Hgb / hemoglobin
HBs Ag / Hepatitis B surface antigen
HCG / human chorionic gonadotrophin
HCl / hydrochloric acid
HCT / hematocrit
HCTZ / hydrochlorithiazide
HCVD / hypertensive cardiovascular disease
HEENT / Head, eyes, ears, nose and throat
HEP / home exercise program
Hg / mercury
HHA / Home Health Aide, Home Health Agency
HHA / Hand held assistance (PT)
HHN / Home Health Nurse
HI / hearing impaired
HIV / human immunodeficiency virus
HMO / Health Maintenance Organization
HOB / head of bed
HOH / hard of hearing
HOH / hand on hand (rehab)
Hosp/HOSP / hospital
HR/R / heart rate and rhythm
HS / heel slide
HS / ham set (rehab)
ht / height
HT / heel taps
HTN / hypertension
Hwy / highway
hx / history
HYDRA / hydration
hyper / above
hypo / below
I / independently, independent
I&D / incision and drainage
I&O / intake and output
i.e. / that is
IADL / independent activities of daily living
ICF / intermediate care facility
ICP / intracranial pressure
ICU / Intensive Care Unit
ID / identification/identify
IDDM / insulin dependent diabetes mellitus
IDG / Interdisciplinary Group
IM / intramuscular
in / inch
INC / increase
IND / independent
inf. / infusion
inhal. / inhalation
INJ / injection
INR / international ratio
Ins. / insurance
inspir / inspiration, inspiratory
instill. / instillation
Instr. / instruction
INT / internal
INT/EXT / internal/external
INTERACTS / interactions
INTERVENT / interventions
IOP / intraocular pressure
IPPB / intermittent positive pressure breathing
IQ / Intelligence quotient
IR / internal rotation
irr., irreg. / irregular
ITC / Interdisciplinary Team Conference
IV / intravenous
IVF / intravenous fluid
IVP / IV push
IVT / intravenous therapy
JMH / Johnston Memorial Hospital
JVD / jugular venous distention
K+ / potassium
KAHC / Kitty Askins Hospice Center
kg / kilogram
L/S/ST / lying, sitting, standing
LA / left atrium
lab / laboratory
lang. / language
lap / laparotomy
LAQ / long arc quad
lat / lateral
lb. / Pound
LBM / loose bowel movement
LBP / low back pain
LBQC / large based quad cane
LD / learning disability
LE / lower extremity
Lg/LGE / large
liq / liquid
LLB / long leg brace
LLE / left lower extremity
LLL / left lower lobe
LLQ / left lower quadrant
LMH / Lenoir Memorial Hospital
LMP / last menstrual period
LOB / loss of balance
LOC / level of consciousness, loss of consciousness, laxative of choice
LP / lumbar puncture
LPN / Licensed Practical Nurse
LPT / Licensed Physical Therapist
LR / lactated Ringer's
LRAD / least restrictive assistive device
LUE / left upper extremity
LUL / left upper lobe
LUQ / left upper quadrant
LVH / left ventricular hypertrophy
lymph / lymphocytes
lytes / electrolytes
m / meter
max / maximum
MCD / Medicaid
mcg / microgram
MCH / mean corpuscular hemoglobin
McK / McKesson
MCL / midclavicular
MCRA / Medicare
MCV / mean corpuscular volume
MD / medical doctor
Meas. / measure
Meds / medications
mEq / milliequivalent
Mg / magnesium
mg. mgm / milligram
MGMT / management
MI / myocardial infarction
MIN / minimal
min / minimum, minute
ml / milliliter
mm / millimeter
MMT / manual muscle test
MOD BORG, BORG / scale to show rate of perceived exertion
mod/MOD / moderate
MOM / milk of magnesia
mono / monocytes, mononucleosis
MR / mentally retarded/medical record
MRSA / Methacillin Resistant Staph Aureus
MS / multiple sclerosis
MSDS / material safety data sheet
MSS / Medical Social Services
MSSP / Master of Science, Speech Pathology
MSW / Master of Social Work
MVA / motor vehicle accident
MVI / multivitamin
MVMT / movement
MVP / Mitral Valve Prolapse
N&V / nausea and vomiting
N/A / not applicable or not addressed
N/S / normal saline
Na / sodium
NA / Nursing Assistant
NaCL / Sodium Chloride
NAD / no acute distress
neg / negative
neuro / neurology
NG / nasogastric
NGT / nasogastric tube
NH3 / ammonia
NHP / nursing home placment
NIDDM / noninsulin dependent diabetes mellitus
NKA / no known allergies
No. / number
noc / night, at night
NOC / Nurse On-Call
norm. / normal
NPI / National Provider Identification Number
NPO / nothing by mouth
NPU / not picked up
nsg. / nursing
NSR / normal sinus rhythm
NTG / nitroglycerin
NWB / non weight bearing
O2 / oxygen
O2 sats / Oxygen saturation
OA / Osteoarthritis
OASIS / Outcome Assessment and Information Set
OB / obstetrics
obj / object
OBS / organic brain syndrome
occ / occasional
OD / overdose
oint / ointment
OJ / orange juice
OOB / out of bed
OOP / out of pocket
OP / ophthalmic
Opth / ophthalmology
OR / operating room/by mouth/oral
Ortho; Orth / orthopedic
OSHA / Occupational Safety and Health Administration
OSTEO / Osteoarthropathies
OT / Occupational Therapy
OTC / over the counter
OTR/L / Occupational Therapist, Registered/Licensed
OX / oximeter
Ox3 / oriented to person, place, time
oz. / ounce
P / pulse
PA / physician's assistant
PAC / Port-a-Cath
PAP / Papanicolaou [test]; peak airway pressure
PARA / paralyzed
Pb / lead
PBI / protein bound iodine
PC / personal care
PCA / personal care aide
PCMH / Pitt County Memorial Hospital
pCO2 / partial pressure of carbon dioxide
PDA / patent ductus arteriosus
PDR / Physician's Desk Reference
PE / physical examination, pulmonary embolism
peds / pediatrics
PEEP / positive end-expiratory pressure
PEG / Percutaneous Endoscopic Gastrostomy
per / by, through
PERF / perform
PERLA / pupils, equal and reactive to light and accommodation
PERRLA / pupils, equal, round, reactive to light and accommodation
PF / plantarflexion
pH / hydrogen concentration
PICC / peripherally inserted central catheter
PID / pelvic inflammatory disease
PLOF/plof / prior level of function
PM / afternoon
PMH / past medical history
PMM / Professional Management Meeting
PNT/pnt / patient
po/PO / by mouth
POA / power of attorney
POC / Plan of Care
polys / polymorphonuclear leukocytes
poplit / popliteal
pos / positive
post / posterior, postvocalic (after vowel)
postop / postoperative
POT / plan of treatment
potent. / potential
PP / postprandial
PPD / purified protein derivative
preop / preoperative
prep / preparation, prepare for
PRES / present
PRN / whenever necessary, as needed
PRNT / parent
PROB / problem
PROF / professional
PROM / passive range of motion
PT / physical therapy
PT/CG / patient/caregiver
PT/INR / prothrombin time/international normalized ratio
PTA / physical therapy assistant
PTT / partial thromboplastin time
PV / peripheral vascular
PVC / premature ventricular contraction
PVD / peripheral vascular disease
PVR / post void residual
PWB / partial weight bearing
q / every
q am / every morning
q2h, q3h, etc. / every two hours, every three hours, etc.
QA / quality assurance
QC / quad cane
qid / four times a day
QS / quad set
R, rt. (R) / right
R/O / rule out
R/T / reference to, related to
RA / rheumatoid arthritis, right atrium
RBC / red blood cell, red blood count
RBS / random blood sugar
rd / road
re / regarding
recep / receptive
REM / rapid eye movement
REPS / repetitions
REQ MIN A / requires minimal assistance
resp / respiration, respiratory
Rh / Rhesus factor
RH / right hand
RHIA / Registered Health Information Administrator
RHIT / Registered Health Information Technician
RLE / right lower extremity
RLL / right lower lobe
RLQ / right lower quadrant
RML / right middle lobe
RN / Registered Nurse
RNOC / RN On-Call
RNS / request no service
ROM / range of motion
RSC / right subclavian
RT / respiratory therapist, therapy
RTC / return to clinic
RTO / return to office
RUE / right upper extremity
RUL / right upper lobe
RUQ / right upper quadrant
RVH / right ventricular hypertrophy
RW / rolling walker
Rx / therapy, treatment, prescription
S / sitting
s/p / status/post
S/S, S&S / signs and symptoms
S/SE / symptoms/side effects
SA node / sinus-atrial node
SaO2 / oxygen saturation in arterial blood
SAQ / short arc quads
SASH / Saline Antibiotics Saline Heparin
SBA / stand by assistance
SE / side effects
SEC / secondary
sed rate / sedimentation rate
SGOT / serum glutamic oxaloacetic transaminase
SGPT / serum glutamic pyruvic transaminase
SLB / short leg brace
SLP / Speech Language Pathologist
SLR / straight leg raise
SMA12 / sequential multiple analysis of 12 chemistry constituents
SMAC / sequential multiple analyzer with compound
SN / skilled nursing
SNF / Skilled Nursing Facility
SNV / Skilled Nursing Visit
SO4 / sulfate
SOB / shortness of breath
SOC / start of care date
SP / Speech Pathologist
SPA / Spanish
SPC / single point cane
spec. / specimen
spon., spont / spontaneous
SPOU / spouse
SPT / stand/pivot/transfer
SR / side rails
SRMC / Sampson Regional Medical Center
SS / Social Security
SSE / soap suds enema
ST, SP Tx / speech therapy
STAT / at once
stim / stimulation
SUBQ / subcutaneous
Sup / Supervision, supervisory
SV / supervisory visit
SVC / superior vena cava
SW / Social Worker
SWAL / swallowing
Sx, sympt / symptoms
Syl. / syllables
T&A / tonsillectomy and adenoidectomy
T, temp / temperature
T.O. / telephone order
t/f / transfer
T/F SPT / transfer (stand, pivot, transfer)
tab / tablet
TB / tuberculosis
TBI / traumatic brain injury
Tbsp / tablespoon
TC&DB or TCDB / turn, cough and deep breathe
TD / transdermal
TDWB / touch down weight bearing
Tech. / technique
Ther act / Therapeutic activities
Ther ex / therapeutic exercises
THR / total hip replacement
TIA / transient ischemic attack
tid, t.i.d. / three times a day
TKR / total knee replacement
tol. / tolerates
TPR / temperature, pulse and respirations
trach / tracheostomy
TSA / total shoulder arthroplasty
TSH / thyroid stimulating hormone
TSM Dressing / Transparent Semipermeable Membrane
tsp / teaspoon
TT / transfer training
TTB / tub transfer bench
TTWB / toe touch weight bearing
TUR / transurethral resection
TURP / transurethral resection prostate; Transurethal Prostectomy
TV / tidal volume
Tx / treatment
UA / urinalysis
UB / upper body
UE / upper extremities
UGI / upper gastrointestinal
UKO / unknown origin
umb / umbilicus, umbilical
UNC / University of North Carolina Chapel Hill
UR / Utilization Review
URI / upper respiratory infection
UTI / urinary tract infection
VA / Veteran's Administration/vaginal
VAD / vascular access device
vag / vaginal
VC/S AD / verbal cues without assistive device
VCS / verbal cues
VD / venereal disease
Vent / ventilator
via / by way of
vit / vitamin
VO / verbal order
vol / volume
VP / venipuncture
VS / vital signs
w/c / wheelchair
w/d / warm and dry
w/o / without
w/p, WP / whirlpool
WBAT / weight bearing as tolerated
WBC / white blood cells, white blood count
WC / wound care
WFL / within functional limits
WilMed / Wilson Memorial Hospital
wk / week
WMC / Wake Medical Center
WMH / Wayne Memorial Hospital
WND / wound
WNL / within normal limits
wt. / weight
x / times
yr / year
* / symbols
/ increase
/ increased
/ decreased
@ / at
~ / approximate
2 / secondary to
° / degree
- / minus, negative
+ / plus, positive
= / equal to
Δ / change
greater than
less than
♂ / male
♀ / female
# / number, pounds
÷ / divided by
% / percent
and
c / with
p / after
s / without
ā / before
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