5.3.01 Approved Medical Abbreviations
CHERRY STREET HEALTH SERVICES
POLICY AND PROCEDURE
SUBJECT:Approved abbreviations and symbols
POLICY:Cherry Street Health Services will maintain a current list of approved abbreviations and symbols. To avoid confusion and possible errors, staff will limit the use of abbreviations and symbols used in patient care documentation to the approved list.
PROCEDURE:
- A list of approved abbreviations and symbols will be developed and maintained by the Safety Committee (see Attachment A).
- The list will be made available to staff during orientation and as additions/changes are made.
- The list will be available online and posted in areas where documentation is likely to occur.
1/13/2006
ATTACHMENT A
APPROVED ABBREVIATIONS AND SYMBOLS
A
Aassessment
(A)axillary
ābefore (ante)
AAAlcoholics Anonymous
Ababortion
acante cebum (before meals)
AC jointacromioclavicular joint
ADright ear- listed unacceptable
ADAAmerican Diabetic Association
ADDattention deficit disorder
ADHDattention deficit hyperactivity disorder
AIDSAcquired Immune Deficiency Syndrome
AKAabove knee amputation
AMAagainst medical advice
Amtamount
ANanorexia nervosa
ANAantinuclear antibody test
AODMadult onset diabetes mellitus
APanteroposterior
APOPTylenol
Approxapproximately
AROMactive range of motion
ASleft ear- listed unacceptable
ASAaspirin
ASAPas soon as possible
Assocassociated/association
ATCaround the clock
AUboth ears – listed unacceptable
AVarteriovenous
AVMarteriovenous malformation
ARaortic regurgitation
ARIacute renal insufficiency
ASaortic stenosis
B
BE, BaEbarium enema
BBSbilateral breath sounds
BCbone conduction (Rinnes test)
BCCCPBreast and Cervical Cancer Control Program
BCPbirth control pill
bid2 times per day
bilatbilateral, bilaterally
BKAbelow knee amputation
BMbowel movement
BMIbasal metobolic rate
BPblood pressure
BPDbronchopulmonary dysplasia
BPHbenign prostatic hypertrophy
BRAT dietbanana, rice cereal, applesauce and toast diet
BSbowel sounds
BSE breast self exam also see SBE –self breast exam
BSObilateral salpingo-oophorectomy
BTLbilateral tubal ligation
BVbacterial vaginitis
Bxbiopsy
C
cwith (cum)
CAcarcinoma
C1…C7cervical vertebrae
Ca++calcium
CADcoronary artery disease
CATcomputed axial tomography
CBCcomplete blood count
cccubic centimeter – on unacceptable list
*CCcomplex case
CCEclubbing, cyanosis or edema
CFSchronic fatigue syndrome
CHDcongential heart disease
CHFcongestive heart failure
Cholcholesterol
CINcervical intraepithelial neoplasia
Circumcircumference
Clchloride
cmcentimeter
CMTcervical motion tenderness
CNScentral nervous system
CN II-XIIcranial nerves 2-12
c/ocomplaint of
COcarbon monoxide
CO2carbon dioxide
COPDchronic obstructive pulmonary disease
CPcerebral palsy
CPEcomplete physical exam
CPRcardiopulmonary resuscitation
C/SCesarean section
CT scancomputed tomography scan
CTAclear to auscultation
CVcardiovascular
CVAcerebral vascular accident
CXRchest X-Ray
D
diamdiameter
DAWdispense as written
d/c or D/Cdiscontinue – listed unacceptable
0 D/Cno discharge
DIDDissociative Identity Disorder
DIPdistal interphalangeal (joint)
dldeciliter
dmdecimeter
DMdiabetes mellitus
DM1diabetes type 1
DM2diabetes type 2
DNRDo Not Resuscitate
D.O.Dr of Osteopathy
DOEdyspnea on exertion
DSSDept of Social Services
DT’sdelirium tremers
DTRdeep tendon reflexes
DUBdysfunctional uterine bleeding
DVTdeep venous thrombosis
Dxdiagnosis
E
E1estrone
E2estrogen (estradiol)
E3esteriol
EaBelective abortion
EACexternal auditory canal
EBVEpstein-Barr virus
ECenteric coated
ECHOechocardiogram
EDEmergency Department
EDCestimated date of confinement
EEGelectroencephalogram
EGAestimated gestational age
EGDesophagastroduodenscopy
EKGElectrocardiogram
EMGelectromyography
ESRDend stage renal disease
ENTears, nose and throat
EOMIextra ocular movements intact
EPSDTearly periodic screening and developmental testing
ERemergency room
ET endotracheal
ERCPendoscopic retrograde cholangiopancreatography
ETOHalcohol
F
FBforeign body
FBGfasting blood glucose
FBSfasting blood sugar
FDLMPfirst day of last menstrual period
Fe+Iron
FHfundal height
FmHxfamily history
FROMfull range of motion
FTIfree thyroxin index
F/Ufollow up
Fxfracture
G
Ggravida
GAgestational age
GCgonorrhea (gonococcus)
GERDgastroesophageal reflux disease
GGgamma globulin
GIgastrointestinal
GLUCglucose
gtt; gttsdrop; drops
GTTglucose tolerance test
GUgenitourinary
GYNgynecology
H
HAheadache
HCGHuman Chorionic Gonadotropin
Hcthematocrit
HCTHydrocortisone
HDhemodialysis
HDLhigh-density lipoprotein
HEENThead, ears, eyes, nose and throat
Hgbhemoglobin
H&Hhemoglobin and hematocrit
HIhomicidal ideation
HIVhuman immunodeficiency virus
HJRhepato-juglar reflux
HMG-CoA3-hydroxy-3methylglutaryl-coenzyme
HNPherniated nucleus pulposus
H/Ohistory of
HOBhead of bed
hosphospital
H&Phistory and physical
HPVhuman papilloma virus
hrhour
HRThormone replacement therapy
hshour of sleep (bedtime)
HSMhepatosplenomegaly
HSVherpes simplex virus
HTNhypertension
H.V.Home visits
HVAhomovanillic acid
hysthysterectomy
Hxhistory
I
Iindependent
IBDinflammatory bowel disease
IBSirritable bowel syndrome
IBUIbuprophen
incl.Including
IDidentification
I&Dincision and drainage
IDDMinsulin dependent diabetes mellitus
i.e.that is
ILDinterstitial lung disease
IMintramuscular
ImmsImmunizations
inptinpatient
IPVinactivated poliovirus vaccine
irregirregular
IVintravenous
IVPintravenous pyelogram
J, K
JVDjugular venous distention
K+potassium
KCHDKent County Health Department
L
Lleft
L1-L5lumbar vertebrae 1-5
lbpound
L&Dlabor and delivery
LElower extremity
LLEleft lower extremity
LLLleft lower lobe (lung)
LLQleft lower quadrant
LMPlast menstrual period
LNMPlast normal menstrual period
LSlumbosacral
LS-spinelumbosacral spine
LSBleft sternal border
LUEleft upper extremity
LUQleft upper quadrant
M
MAmedical assistant
mcgmicrogram
MCLmidclavicular line
MCPmetacarpophalangeal joint
M.D.Medical Doctor
MDMuscular dystrophy
MDImetered-dose inhaler
Med (s)medication, medications
mEqmilliequivalent
MFMmaternal fetal medicine
mgmilligram
MImyocardial infarction
MMRmeasles, mumps and rubella
0 M/G/Rno murmur/gallops/or rubs
MPmetacarpophalangeal joint
MRmitral regurgitation
MRIMagnetic Resonance Imaging
MSSMaternal Support Services
MSWMaster’s of Social Work
MTPmetatarsophalangeal joint
MVAmotor vehicle accident
MVPmitral valve prolapse
N
NADno acute distress
NCTnerve conduction test
NC/ATnormocephalic/atraumatic
Nd/NT, + BSnon-distended/non-tender, + bowel sounds
N, Nnitrogen
NCVnerve conduction velocity
negnegative
neuroneurologic
NGnasogastric
NIDDMnon-insulin dependent diabetes mellitus
NKMAno known medical allergies
NSnormal saline
NSAIDnonsteroidal anti-inflammatory drug
NSRnormal sinus rhythm
N/Vnausea and vomiting
NVDnormal vaginal delivery
O
O. objective
(O)oral
O2oxygen
Ob/gynobstetrics/gynecology
OCP’soral contraceptive pills
OCDObsessive Compulsive disorder
ODright eye
OEotitis externa
OMotitis media
outptoutpatient
OPVoral polio vaccine
OSleft eye
OTCover the counter
OUboth eyes
ozounce
P
Pplan
pafter
PA-CPhysician Assistant –Certified
Pap smearpapanicolaou smear
pcafter meals
PCPprimary care provider
PEphysical exam
PEFRpeak expiratory flow rate
PEGgastrostomy tube
PERRLApupils are equal, round, reactive to light and accommodation
PHDPublic Health Department
PHNPublic Health Nurse
Phosphosphorus
PIDpelvic inflammatory disease
PIPproximal interphalangeal joint
PMHpast medical history
PNprogress notes
PNDparoxysmal nocturnal dyspnea
PNV Prenatal vitamins
poby mouth
pospositive
pppost prandial
PPBpap, pelvic and breast
ppdpacks per day
PPDpurified protein derivative (of TB)
PRper rectally
Pregpregnant
Prnas needed
PROprotein
Pro timeprothrombin time
PSAprostate specific antigen
PSHpast surgical history
ptpatient
PTphysical therapy
PTSDpost traumatic stress disorder
PUDpeptic ulcer disease
Pulmonary HTNpulmonary hypertension
PVDperipheral vascular disease
Q
qevery
QDevery day – on unacceptable list
qidfour times per day
qodevery other day – listed unacceptable
R
®; rtright
RArheumatoid arthritis
RBCred blood cell
RBGrandom blood glucose
RBSrandom blood sugar
RCCRapeCrisis Center
RCMright costal margin
RDRegistered Dietician
RDSrespiratory distress syndrome
Re:regarding
resprespiratory
RFrheumatoid factor
RHDrheumatic heart disease
RIrenal insufficiency
RLEright lower extremity
RLLright lower lobe (lung)
RLQright lower quadrant
RNRegistered Nurse
R/Orule out
ROMrange of motion/ rupture of membranes
ROVreturn office visit
RRRregular rate and rhythm
RSBright sternal border
RSRregular sinus rhythm
RSVrespiratory syncytial virus
RUEright upper extremity
RUQright upper quadrant
Rxprescription
S
Ssubjective
swithout
SABspontaneous abortion
SBEself breast exam
Schschedule (d)
S/Eside effects
Sed ratesedimentation rate
SGSpecific Gravity
SHxsocial history
Short ICPshort intracontraceptual period
SIsacroiliac
S/Isuicide ideation
SILsquamous intraepithelial lesion
SLsublingual
SLEsystemic lupus erythematosus
SLRstraight leg raise
SMACsequential multiple analyzer – chemistries
SOsignificant other
SOBshortness of breath
SQ subcutaneous
S/Pstatus post
S/Sxsigns and symptoms
STATimmediately
STDsexually transmitted disease
SubQsubcutaneous – listed on unacceptable list use SQ
SVTsupraventricular tachycardia
T
T1…T12thoracic vertebrae 1-12
T3triiodothyronine
T4thyroxine
T7free thyroxin factor
Tabtablet
TABtherapeutic abortion
TBtuberculosis
TDTetanus-diptheria toxoid (child type)
TdTetanus-diptheria toxoid (adult type)
tbsptablespoon
temptemperature
TIBCtotal iron-binding capacity
Tib/fibtibia/fibula
tidthree times per day
TMtympanic membrane
TMJtemporomandibular joint
TPRtemperature, pulse and respiration
TRtricuspid regurgitation
TStricuspid stenosis
TSHthyroid-stimulating hormone
tspteaspoon
Type 1 DMType one Diabetes Mellitus
Type 2 DMType two Diabetes Mellitus
Txtreatment
U
UAurinalysis
UCurine Culture
UEupper extremity
UGIupper gastrointestinal
URIupper respiratory infection
U/Sultra sound
UTIurinary tract infection
V
VCUGvoiding cystourethrogram
V-tachventricular tachycardia
VNvisiting nurse
VNAVisiting Nurse Association
vsversus
VSvital signs
VSSvital signs stable
W, X, Y and Z
w/uwork up
WBCwhite blood cell
WCCwell child check
WDWNwell-developed, well nourished
WFLwithin functional limits
WICWomen Infants, hildren (program) testing
wkweek
WNLwithin normal limits
0 W/R/Rno wheezes/rales/rhonci
xtimes
xexcept
yryear
Znzinc
HOSPITALS
S.H.D.C.Spectrum Downtown Health Campus
S.H.E.C.Spectrum East Campus
SH BMMC Spectrum Health Blodgett Campus
SMHSaint Mary’s Hospital
MetroMetropolitan
CSHS FACILITY NAME ABBREVIATIONS
BEBelknap
BHCBurtonHealthCenter
BOBooth
CSHSCherryStreetHealthCenter
FAHC FergusonAdultHealthCenter
FDHCFergusonDentalHealthCenter
GRPGrand Rapids Pediatrics
H.I.S.Health Intervention Services
UHSHCUnionHighSchoolHealthCenter
WSHCWest SideHealthCenter
OPTICAL ABBREVIATIONS
ACAnterior Chamber
APDApparent pupilary defect
ARMDAge related macular degeneration
AVArtery to vein ratio
CATSCataract
CDCup to disc ratio
DESDry Eye Syndrome
EpEsophoria
EtEsotropia
IOPIntraoccular Pressure
LEELast Eye Exam
LLCLens, lid, cornea
LLLLower left lid
LRLLower right lid
NPCNear point conversion
OAGOpen Angle Glaucoma
ODDoctor of Optometry
ODRight Eye
OSLeft Eye
OUBoth Eyes
PDPupilary Distance
PERRLAPupil equal round reactive to light accommodation
RDRetinal detachment
SLESlit lamp examination
ULLUpper left lid
URLUpper right lid
VAVisual Acuity
VFVisual Field
WNLWithin normal limits
XpExophoria
XtExotropia
5/95 R 5/97
R5/99,R6/00
RX/04
Reviewed 1/06
1