1011 - Abbreviation List -- Medical

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					POLICY & PROCEDURE MANUAL                                                            POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                                       PAGE 1 of 12


STANDARD:

The Medical Abbreviation List serves as a legend for approved abbreviation terminology that may be
used in the medical records.

POLICY:

Only those medical abbreviations appropriate to this facility are included. Contents are separated into
three sections:
        •       Section I:       Medical Abbreviations
        •       Section II:      Symbols
        •       Section III:     Titles of Disciplines
Ophthalmological abbreviations are designated with a single asterisk (*), and the abbreviated terms are
documented only on the consultation reports to eliminate misinterpretation. Rehabilitation department's
abbreviations for manual muscle test grades, which includes good (G), fair (F), poor (P), and normal (N),
are designated with a double asterisk (**). The Medical Abbreviation List is reviewed and revised at least
annually by the medical director, department of nursing services, and the medical record department.

APPROVED LIST

Section I:                    Medical Abbreviations

                                             A.

        AAROM                   active assistance range of motion
        abd             .       abdomen
        ABG                     arterial blood gases
        a.c.                    before food
        AC                      anterior chamber *
        ADA                     American Dietetic Association
        ADL                     activities of daily living
        ad. lib.                as desired
        ADM                     admission
        AFB                     acid-fast bacillus
        A. Fib.                 atrial fibrillation
        AFO                     ankle foot orthosis
        AG. Ration              albumin/globulin ration
        AIDS                    auto - immune deficiency syndrome
        AK                      above knee (amputation)
        Alb.                    Albumin
        Alk.                    Alkaline
        ALS                     amyotrophic lateral sclerosis
        ALT                     alanine transaminase
        A.M.                    morning
        AMI                     acute myocardial infarction
        AMA                     against medical advice
        amb.                    ambulate, ambulatory
        amp.                    Ampul
        amt.                    amount
        ANA                     antinuclear antibody
        ant.                    Anterior
        AODM                    adult onset diabetes mellitus
        A/P                     anterior / posterior
        A+P                     auscultation + percussion
POLICY & PROCEDURE MANUAL                                            POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                     PAGE 2 of 12


      approx.              approximate
      appt.                appointment
      AP                   apical pulse
      ARDS                 adult respiratory distress syndrome
      ARF                  acute renal failure
      AROM                 active range of motion
      AS                   aortic stenosis
      ASA                  aspirin
      ASAP                 as soon as possible
      ASCVD                arteriosclerotic cardiovascular disease
      ASHD                 arteriosclerotic heart disease
      ATC                  around-the-clock
      AV                   arteriovenous, atrioventricular
      AVR                  aortic valve replacement
      A wave               atrial contraction waves
      Ax.                  axis of cylinder lens *

                                 B
      Baso                 basophil
      BBB                  bundle branch block
      BE                   barium enema
      BID                  twice a day
      Bilat                Bilateral
      BKA                  below the knee (amputation)
      Bin                  twice a night
      BM                   bowel movement
      B.M.E.               behavior, mentation, emotion
      BP                   blood pressure
      BPH                  benign prostatic hypertrophy
      BR                   bathroom
      BRP                  bathroom privileges
      BS                   blood sugar
      b.s.                 bowel sound
      BUN                  blood urea nitrogen
      Bx.                  biopsy

                                  C
      C                    Centigrade (Celsius)
      c                    with
      C1,2,3,4,5,6,7       cervical vertebra 1 -7
      Ca+                  calcium
      CA                   carcinoma
      CAD                  coronary artery disease
      cal.                 calorie
      cap.                 capsule
      CAT                  computerized axial tomography
      cath                 catheter (size)
      CBC                  complete blood count
      CBD                  common bile duct
      CBI                  constant bladder irrigation
      CC                   chief complaint
      cc.                  cubic centimeter
      cc                   with correction *
POLICY & PROCEDURE MANUAL                                                          POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                                   PAGE 3 of 12


      CCU                  coronary care unit
      chemo                chemotherapy
      CHF                  congestive heart failure
      CI                   cardiac index
      CG                   Caregiver
      CX                   Culture
      CM                   Case Manager
      Chol                 Cholesterol
      CBC D/P              Complete blood count with differential and platelets.
      CL                   chloride
      CLL                  chronic lymphocytic leukemia
      cm.                  centimeter
      CN                   cranial nerve
      CNS                  central nervous system
      C.O.                 cardiac output
      C/O                  complained of
      CO2                  carbon dioxide
      COAG                 chronic open angle glaucoma *
      COPD                 chronic obstruction pulmonary disease
      CP                   cardio/pulmonary
      CPK                  creating phosphokinase
      CPR                  cardiopulmonary resuscitation
      CPT                  chest physio-therapy
      CRF                  chronic renal failure
      C&S                  culture and sensitivity
      CSF                  cerebrospinal fluid
      CTS                  carpal tunnel syndrome
      CVA                  cerebrovascular accident
      CXR                  chest X-ray
      cysto.               cystoscopy
      cyl                  cylinder or cylindric lens *

                                 D
      D1,2,3,4,5,6,7       dorsal vertebra 1-7
      D5NS or 5% DNS       5% dextrose in normal saline
      D51 / 2NS or
      5% D1 / 2NS          5% dextrose in half normal saline
      D5W or 5% DW         5% dextrose in water
      db.                  decibel
      de                   desired effect
      D&C                  dilatation and curettage
      d/c                  discontinued
      decub.               decubitus
      DIFF                 differential blood count
      dil.                 dilute
      D/C                  discharge
      DJD                  degenerative joint disease
      DM                   diabetes mellitus
      DNR                  do not resuscitate
      DOE                  dyspnea on exertion
      DP                   dorsalis pedis (pulse)
      drsg                 dressing
      DSD                  dry sterile dressing
      DTR                  deep tendon reflexes
POLICY & PROCEDURE MANUAL                                                      POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                               PAGE 4 of 12


      Dx.                  Diagnosis

                                E

      ECCE                 extracapsular cataract extraction *
      ECF                  extended care facility
      ECG or EKG           electrocardiogram
      EEG                  electroencephalogram
      EENT                 eyes, ears, nose, throat
      e.g.                 for example
      elix.                Elixir
      EMG                  electromyogram
      ENT                  ears, nose, throat
      EOM                  extraocular movement
      Eos.                 Eosinophil
      epith.               Epithelial
      EPS                  extrapyramidal symptoms
      equiv.               equivalent
      ER                   emergency room
      ESCD                 end-stage cardiac disease
      ESR                  erythrocyte sedimentation rate
      ESRD                 end-stage renal disease
      EST or ECT           electroshock therapy or electroconvulsive therapy
      ET                   esotropia at distance *
      Et'                  esotropia at near *
      ETOH                 alcohol
      eval.                Evaluation
      exam.                Examination
      Ext. Rot.            external rotation

                                  F
      F                    Fahrenheit, fair **
      FBS                  fasting blood sugar
      Fe                   iron
      FeSO4                ferrous sulfate
      FEV2                 foreign expiratory volume per second
      FH                   family history
      FSBS                 Fingerstick blood sugar
      fld.                 Fluid
      flex.                Flexion
      freq.                frequency
      ft.                  foot, feet
      FT                   facilitation techniques
      F/U                  follow up
      FUO                  fever, unknown origin
      FWB                  full weight bearing
      Fx.                  Fracture

                                  G
      Dx.                  Diagnosis
      GA                   gastric analysis
      GB                   gallbladder
      G/C                  gerichair
      GI                   gastrointestinal
POLICY & PROCEDURE MANUAL                                        POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                 PAGE 5 of 12


      Gm.                  Gram
      gr.                  Grain
      G/T or G Tube        gastrostomy tube
      Gt. Tr.              gait training
      GTT                  glucose tolerance test
      gtt.                 Drop
      GU                   genitourinary
      GYN                  gynecology

                                 H
      H2 O                 water
      H2 O 2               hydrogen peroxide
      HBP                  high blood pressure
      HCI                  hydrochloric aid
      HCT                  hematocrit
      hd                   hemo – dialysis
      HEENT                head, eyes, ears, nose, throat
      Hgb                  hemoglobin
      Hgt or Ht.           height
      HHN                  hand-held nebulizer
      H&H                  hematocrit and hemoglobin
      HHA                  home health aide
      HIV                  Human Immunodeficiency Virus
      HM                   hand movement *
      H/O                  history of
      HP                   hot packs
      H&P                  history and physical
      hr.                  hour
      HS                   bedtime
      HTN                  hypertension
      HX                   history

                                  I
      IBC                  iron-binding capacity
      IDDM                 Insulin dependent diabetes mellitus
      ICCE                 intracapsular cataract extraction
      IVC                  intravenous cholangiogram
      IVP                  intravenous pyelogram
      IVPB                 intravenous piggyback

                                  J
      J1,J2, etc.          Jaeger test type for near vision *
      J.M.                 joint mobilization
      J. tube              jejunostomy tube

                                  K
      K+                   potassium
      KC                   kilo calorie
      KCL                  potassium chloride
      kg.                  kilogram
      KP                   keratic precipitates
      KUB                  kidney, ureter, bladder
      KVO, TKO             keep vein open
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TITLE: Abbreviation List -- Medical                                       PAGE 6 of 12


                                   L
      l                    liter
      L                    left
      L1,2,3,4,5           lumbar vertebra 1-5
      LA                   left atrium
      lab                  laboratory
      lac.                 laceration
      lb                   pounds
      LBBB                 left bundle branch block
      LDH                  lactic dehydrogenase
      LE                   lower extremity
      LFT                  liver function test
      LH                   left hyperphoria *
      LHT                  left hypertropia *
      Liq.                 Liquid
      LLB                  long leg brace
      LLE                  left lower extremity
      LLL                  left lower lobe (lung)
      LLQ                  left lower quadrant (abdomen)
      LMCA                 left middle cerebral artery
      LOA                  leave of absence
      LOC                  loss of consciousness
      LP                   lumbar puncture
      LTG                  long-term goal
      LUE                  left upper extremity
      LUL                  left upper lobe (lung)
      LV                   left ventricle
      LVH                  left ventricular hypertrophy
      Lymp                 lymphocyte
      lytes                electrolytes (NA, K, C, CO2)

                                  M
      m                    meter
      MA                   mat activities
      MAT                  multifocal atrial tachycardia
      max.                 maximum
      mcg., mg             microgram
      MCA                  middle cerebral artery
      MCH                  mean corpuscular hemoglobin
      MCHC                 mean corpuscular hemoglobin concentration
      MCP                  metacarpophalangeal joint
      meq                  milliequivalent
      Mg+                  magnesium
      mg                   milligram
      MI                   myocardial infarction
      min.                 minute
      MMT                  manual muscle test
      mod.                 Moderate
      MOM                  milk of magnesia
      MR/MI                mental retardation/mental illness
      MRI                  magnetic resonance imaging
      M.S.                 multiple sclerosis
      MSQ                  mental status quotient
      M.T.                 mobility training
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TITLE: Abbreviation List -- Medical                                     PAGE 7 of 12


                                N

      Na+                  sodium
      N/A                  not applicable
      N/C                  no complaints
      neg.                 negative
      N/G                  nasogastric
      NIDDM                non-insulin dependent diabetes mellitus
      NKDA                 no known drug allergies
      NKA                  no known allergies
      NNO                  no new orders
      no.                  number
      noc.                 Night
      NPO                  nothing by mouth
      NS                   normal saline
      Nsg.                 Nursing
      NSR                  normal sinus rhythm
      n/t                  not tested
      NTG                  nitroglycerin
      N&V                  nausea and vomiting
      NWB                  nonweight bearing

                                  O
      O                    objective findings
      O2                   oxygen
      OA                   osteoarthritis
      Ob/Gyn               obstetrics and gynecology
      OBS                  organic brain syndrome
      OD                   right eye (oculus dester) *
      OOB                  out of bed
      OBT                  obtained
      O/P                  orthotics/prosthetics
      O&P                  ova and parasites
      OPD                  outpatient department
      OR                   operating room
      OS                   left eye
      O.T.                 occupational therapy
      OU                   both eyes
      oz.                  ounce

                                  P
      p                    pulse
      p                    after
      PA                   posterior / anterior
      PAC                  premature atrial contraction
      Pap. Smear           Papanicolaou smear
      PAT                  paroxysmal atrial tachycardia
      path.                pathology
      p.c.                 after meal
      PCG                  pati ent caregiver
      PCH                  personal care home
      PCN                  penicillin
      PCO2                 carbon dioxide pressure
POLICY & PROCEDURE MANUAL                                                POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                         PAGE 8 of 12


      P&PD                 percussion & postural drainage
      PDR                  Physician Desk Reference
      PE                   physical examination
      per                  through
      PERL                 pupils equal, reactive to light
      PERRLA               pupils, equal, round, reactive to light and
                           accommodation
      pH                   hydrogen ion concentration
      PI                   present illness
      PIP                  proximal interphalangeal joint
      P/M                  perceptual - motor
      P.M.                 evening
      PMH                  past medical history
      PMI                  point of maximal impulse
      PMR                  polymyalgia rheumatic
      PO                   by mouth
      POR                  problem - oriented record
      post-op              postoperative
      PPD                  purified protein derivative
      2 PP                 two - hour postprandial (blood sugar)
      PRE                  progressive resistance exercise
      pre-op               before surgery
      prep.                prepare for surgery
      PRN                  as needed
      Procto               proctoscopic; proctology
      PROM                 passive range of motion
      psych.               psychiatry
      pt.                  patient
      P.T.                 physical therapy
      PT                   prothrombin time
      PTA                  prior to admission
      PTB                  patellar tendon bearing
      PTT                  partial prothromboplastin time
      PUD                  peptic ulcer disease
      pulm.                pulmonary
      PVC                  premature ventricular contraction
      PVD                  peripheral vascular disease
      PWB                  partial weight bearing

                                  Q
      q                    every
      qd                   every day
      q4h, q5h, etc        every four hours, every five hours, etc.
      q.h.s.               every night
      qid                  four times a day
      q.m.                 every morning
      q.n.                 every night
      q.n.s.               quantity not sufficient
      q.o.d.               every other day
      q.s.                 sufficient quantity
      quant.               quantity
POLICY & PROCEDURE MANUAL                                            POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                     PAGE 9 of 12




                                  R
      R                    rectal
      R                    respiration
      R or Rt.             right
      RA                   rheumatoid arthritis
      RAI                  radioactive iodine uptake
      RBBB                 right bundle branch block
      RBC                  red blood cell
      R.D.A.               recommended daily allowance
      rec.                 recreation
      rehab.               Rehabilitation
      REM                  rapid eye movement
      resp.                respiratory
      re:                  related to
      Rh.                  Rhesus factor in blood
      RHD                  rheumatic heart disease
      RLE                  right lower extremity
      RLL                  right lower lobe (lung)
      RLQ                  right lower quadrant
      R&M                  routine and microscopic (urinalysis)
      RMCA                 right middle cerebral artery
      RML                  right middle lobe (lung)
      RNA                  ribonucleic acid
      R/O                  rule out
      ROM                  range of motion
      ROS                  review of systems
      RSR                  regular sinus rhythm
      RT                   respiratory therapy
      RUE                  right upper extremity
      RUL                  right upper lobe (lung)
      RUQ                  right upper quadrant
      RV                   right ventricle
      RVH                  right ventricular hypertrophy
      Rx.                  prescription

                                   S
      s                    without
      S/A                  sugar and acetone
      SBE                  subacute bacterial endocarditis
      SQ or Sub. Q         subcutaneous
      SDAT                 senile dementia Alzheimer's type
      sed. rate            sedimentation rate
      SEM                  systolic ejection murmur
      SGOT                 serum glutamic oxaloacetic transaminase
      SGPT                 serum glutamic pyruvic transaminase
      SH                   social history
      sig.                 let it be written
      SL                   sublingual
      SLB                  short leg brace
      SM                   sensory motor
      SMIG                 sensory motor integration group
POLICY & PROCEDURE MANUAL                                            POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                    PAGE 10 of 12

      SNF                  skilled nursing facility
      SN                   skilled nurse
      SNV                  skilled nurse visit

      SOAP                 subjective, objective, assessment, plan
      SOB                  shortness of breath
      soln.                solution
      S/P                  status post
      spec.                specimen
      sp. gr.              specific gravity
      SSE                  soapsuds enema
      SSKI                 saturated solution potassium iodide
      S.T.                 speech therapy
      staph.               staphylococcus
      STAT                 immediately, at once
      STG                  short term goal
      strep.               streptococcus
      surg.                surgery
      SVT                  supraventricular tachycardia
      S/S                  sign & symptoms
      Sz                   seizure

                                   T
      T                    temperature
      T1                   first thoracic vertebra
      T3                   3,5,3 - triiodothyronine
      T4                   thyroxine
      T-7                  free thyroxine factor
      TB                   tuberculosis
      tbsp.                tablespoon
      TCDB                 turn, cough, deep, breathe
      T&C                  type and cross-match
      tele                 telemetry
      TF                   tube feeding
      TIA                  transient ischemic attack
      TIBC                 total iron binding capacity
      TID                  three times a day
      TLC                  tender loving care
      TM                   tympanic membrane
      T max                maximum temperature
      TMJ                  temporomandibular joint
      TNS                  transcuaneous nerve stimulation
      T.O.                 telephone order
      TPR                  temperature, pulse, respiration
      TRIG                 triglycerides
      Tr.Tr.               transfer training
      TSH                  thyroid-stimulating hormone
      tsp.                 teaspoon
      TT                   tilt table
      TUR                  transurethral trisection
      TURP                 transurethral resection of the prostate
      TWE                  tap water enema
      Tx.                  treatment

                                 U
POLICY & PROCEDURE MANUAL                                         POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                 PAGE 11 of 12

      U/A                  urinalysis
      UE                   upper extremity


      UGI                  upper gastrointestinal (series)
      ung.                 Ointment
      URC                  utilization review coordinator
      URI                  upper respiratory infection
      US                   ultrasound
      USP                  United States Pharmacopoeia
      UTI                  urinary tract infection

                                  V
      VD                   venereal disease
      VDRL                 venereal disease research laboratory
      VF                   ventricular fibrillation
      vit.                 Vitamin
      VNA                  visiting nurse association
      V.O.                 verbal order
      VPC                  ventricular premature contractions
      v.s.                 vital signs
      vs.                  versus
      V tach.              ventricular tachycardia

                                 W
      WBC                  white blood cell count
      W/C                  wheelchair
      W/C Tr.              wheelchair training
      WFL                  within functional limits
      Wgt. Or Wt.          weight
      WNL                  within normal limits
      WP                   whirlpool
      W/U                  workup
      WDWN                 well developed, well nourished

                                 X
      x                    times
      XT                   exotropia at distance *
      XT'                  exotropia at near *

                                 Y
      y.o.                 year old

SECTION II: SYMBOLS

                           up, increase
                           down, decrease
      <                    less than
      >                    greater than
      ^                    dram
      oz.                  ounce
      m                    murmur
      II                   parallel bar
      "                    inch
      '                    foot, feet
POLICY & PROCEDURE MANUAL                                              POLICY NO. 1011

TITLE: Abbreviation List -- Medical                                      PAGE 12 of 12

      ~                    approximately
      •                    degree
      @                    at

      2                    secondary
      /                    per

SECTION III TITLES OF DISCIPLINES

      ACSW                 Academy of Certified Social Workers
      ART                  Accredited Record Technician
      BSW                  Baccalaureate in Social Work
      CNA                  Certified Nursing Assistant
      COTA                 Certified Occupational Therapy Assistant
      COTA/L               Certified / Licensed Occupational Therapy
                                   Assistant
      DDS                  Doctor of Dental Surgery
      DMD                  Doctor of Dental Medicine
      DPN                  Doctor of Podiatry
      Dr                   Doctor
      Ed. D                Doctor of Education
      LVN                  Licensed Vocational Nurse
      MD                   Medical Doctor
      MSW                  Masters in Social Work
      MT (ASCP)            Registered and Licensed Occupational
                                   Therapist
      OTS                  Occupational Therapy Student
      PTA                  Physical Therapy Assistant
      RA                   Restorative Aide
      RD                   Registered Dietician
      RCP                  Respiratory Care Practitioner
      RN                   Registered Nurse
      RNC                  Registered Nurse Certified
      RNCNA                Registered Nurse, Certified in Nursing

                                 Administration
      RNNP                 Registered Nurse Nurse Practitioner
      RPh.                 Registered Pharmacist
      RPT                  Registered Physical Therapist
      SPT                  Student Physical Therapist
      TRD                  Therapeutic Recreation Director

				
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