IN House memo  you can use to translate VA medical records

 

Central Alabama Veterans Health Care System CAVHCS

 

Memorandum No. 136-01-06

Approved Abbreviations and Symbols list

 

1.             PURPOSE: To state policy, assign responsibility, and provide procedures for maintaining the list of approved abbreviations and symbols to be used in the medical records at Central Alabama Veterans Health Care System (CAVHCS) and maintain the Prohibited Abbreviation List.

 

2.            POLICY: It is the policy of this health care system that only approved abbreviations and symbols listed in this policy are used in the medical records (includes hard copy and electronic medical records, handwritten and typed).

 

3.            RESPONSIBILITIES:

 

a.       The Health Care System Director has the ultimate responsibility for ensuring that health care providers utilize these abbreviations and symbols in the medical records.

 

b.      All Health Care Practitioners, who make entries in the medical records, will use only those approved abbreviations and symbols listed in this policy.

 

c.       The Medical Records Committee will monitor medical records entries, to ensure adherence to this policy through routine medical record reviews.

 

d.      The Medical Records Committee makes recommendations to the Information Management Council for corrective action(s) and revisions.

 

4.             PROCEDURES:

 

a.       Requests for additions and deletions to the Abbreviations and Symbols List (Attachment A) or to the Prohibited Abbreviation List (Attachment B) will be submitted in writing from service line managers to the Medical Records Committee.

 

b.      Final diagnoses listed on the discharge summary will be recorded in full without the use of abbreviations or symbols.

 

c.       Staff may also access the approved abbreviations and symbols list on the V-Drive under Health Administration Service (HAS-136) policies. The list will be linked to CPRS to provide efficient provider access.

 

5.             REFERENCES: m-1, Part 1, Chapter 5; JCAHO Accreditation Manual for Hospitals; JCAHO List of Unapproved Abbreviations.

6.             RESCISSIONS: cavhcs Memorandum No. 136-01-06, dated July 9, 2001.

 

7.             RECERTIFICATION DATE: This document is scheduled for recertification on/before the last working day of July 2007.

 

8.             FOLLOW-UP RESPONSIBILITY: 136

 

 

 

N. Rao Chava, MD

Acting Director, Central Alabama Veterans Health Care Sysgem

 

Attachment A: Approved Abbreviations List

Attachment B:  Prohibited Abbreviations List

 

 

Distribution: C & F

 


Memorandum No. 136-01-06    APPROVED ABBREVIATIONS LIST           Attachment A

December 23, 2003

 

ABBREVIATION            STANDS FOR

A1                               first aortic sound

A2                               second aortic sound

A&A                           Aid and Attendance

AA                               authorized absence

AAA                            abdominal aortic aneurysm

A-ADD                       Adult Attention Deficit Disorder

aaf                               African American female

AAL                            anterior axillary line

aam                             African American male

AB                               abortion

Abd                             abdomen

ABD                            abductor

ABG                            arterial blood gases

ABLB                         alternate binaural loudness balance

ACB                            before breakfast

Acid phos.                   acid phosphate

ACL                            anterior cruciate ligament

ACLS                          Advance Cardiac Life Support

ACS                            before supper

ACTH                         Adrenocorticotropic hormone

A.D.                            right ear

Ad lib                          as much as desired

ADA                            American Diabetic Association

ADD                           adductor

ADE                            adverse drug event

ADH                           antidiuretic hormone

ADL                            activities of daily living

Aeb                             as evidence by

AFB                            acid-fast bacillus (TB)

AFIP                           Armed Forces Institute of Pathology

AFib                            atrial fibrillation

AFL                             atrial flutter

AFO                            ankle foot orthosis

AG                              albumin-globulin ratio

AHA                            American Heart Association

AHHD                        arteriosclerotic hypertensive heart disease

AI                                aortic insufficiency

AIDS                           acquired immunodeficiency syndrome

AJ                               ankle jerk

AKA                            above knee amputation

ALA                            delta aminolevulinic acid

Alb.                             albumin

Alk. Phos.                   alkaline phosphatase

Alk.p’tase                   alkaline phosphatase

AIPS                           aphasia Language Performance Scales

ALS                             Amyotrphic Lateral Sclerosis

Alveo                          alveolectomy

ALT                            alanine aminotransferase

AM                             morning

AMA                           against medical advise

AMI                            anterior myocardial infarction

amp                             ampule

amt                              amount

ante                             before

ANA                            antinuclear antibody

ANF                            antinuclear factor

ant                               anterior

A & P                          auscultation and percussion

A-P                              anterior-posterior

AP                               abdominoperineal

AP & Lat                    anteroposterior and lateral

APC                            atrial premature contraction

appt                             appointment

as tol                           as tolerated

APVD                         arteriosclerotic peripheral vascular disease

ARDS                         adult respiratory distress syndrome

ARF                            acute renal failure

ARI                             acute renal insufficiency

AS                               aortic stenosis

A.S.                             left ear

ASA                            acetylsalicylic acid

ASAP                          as soon as possible

ASCUS                       atypical squamous cells of undetermined significance

ASD                            atrial septal defect

ASHD                         arterisclerotic heart disease

ASO                            antistreptolysin O

AST                             aspartate aminotransferase

ASTRA-7                    chemistry 7

AT                               atraumatic

ATN                            acute tubular necrosis

AV                               arteriovenous; atrioventricular

AVL                            atrioventricular lead

AVM                           arteriovenous malformation

AWOL                        absent without leave

 

B                                 black

baso                            basophil

BBB                            bundle branch block

BC                               bone conduction

BCM                           below costal margin

BCR Studies              breakpoint cluster region (bloodwork)

BE                               barium enema

BF                               black female

bf                                 biofeedback

b.i.d.                            twice a day

biPAP                          non-invasive pressure support ventilator

BKA                            below knee amputation

BM                             black male

bm                               bowel movement

BMI                            body mass index

BMJ                           bulbomembranous junction

BMR                          basal metabolic rate

BP                               blood pressure

BPH                            benign prostatic hypertrophy

BR                              bed rest

BRP                            bathroom privileges

BS                               bowel sounds

BSS                             Balanced Salt Solution

BT                               blind rehabilitation therapy

bs                                breath sounds

BSR                            bed side rails

BUN                            blood urea nitrogen

BV                               bacterial vaginosis

BW                              body weight

BX                               biopsy

 

oC                                centigrade

C                                 cornea

C-1,C-2, etc                cervical vertebrae 1-7

c                                  with

CA                               carcinoma

CAB                            coronary artery bypass

CABG                         coronary artery bypass graft

CAD                            coronary artery disease

Cal, Kal                      Calorie/Kilocarie

CAPD                         chronic ambulatory peritoneal dialysis

caps                             capsule

CAST Study               cardia arrhythmic suppression

cath.                            catheter

CBC                            complete blood count

/C                                mandibular complete denture

C/                                maxillary complete denture

C/C                              maxillary & mandibular complete dentures

CBD                            common bile duct

CBP                            chronic back pain

CBS                            chronic brain syndrome

C.C.                             chief complaint

CCT                            certified corrective therapist

CCU                            coronary care unit

CD                              cup disc ratio

ceph.floc                     cephalin flocculation test

Cf 3’                            count finger vision at 3 feet

CHEM 7                     glucose, BUN, creatine, potassium, sodium, chloride, CO2

CHF                            congestive heart failure

CHO                           carbohydrate

CHOL                         cholesterol

C1                               chloride (T)

cldy                             cloudy (T)

CMAP                                    compound muscle action potential (T)

CRC                            Community Residential Care (T)

CLBP                          chronic lower back pain

cm                               centimeter

CMV                           cytomegalic virus

CNH                           Community Nursing Home

CNS                            central nervous system

CO                              carbon monoxide

c/o                               complaints of

CO2                            carbon dioxide

COAG             chronic open angle glaucoma (T)

COLD                         chronic obstructive lung disease

COPD                         chronic obstructive pulmonary disease

C&P                            compensation and pension examination

CPC                            clinicopathological conference

CPAP                          continuous position airway pressure

CPK                            creatine phosphokinase

CPK-BB                     creatine phosphokinase isoenzyme, brain

CPK-MB                    creatine phosphokinase isoenzyme, cardiac muscle fraction

CPK-MM                   creatine phosphokinase isoenzyme, skeletal muscle fraction

CPR                            cardiopulmonary resuscitation

CRCS                         colorectal cancer screening

CRF                            chronic renal failure

CRI                             chronic renal insufficiency

CRRC                         Coronary Risk Reduction Clinic

C&S                            culture and sensitivity

CSF                             cerebrospinal fluid

CSP                             Community Service Program

C-Spine                       cervical spine

CT                               Corrective Therapy

CAT scan                    computerized axial tomography

CTS                             carpal tunnel syndrome

CTA                            clear to auscultation

CTPN                          central total parenteral nutrition

cv                                costovertebral angle

CVN                            central venous nutrition

CV                               cardiovascular

CVA                            cerebrovascular accident

CVP                            central venous pressure

CVS                            cardiovascular system

CW                              chest wall

CXR                            chest x-ray

 

D’s + V’s                    ductions + versions

D-1,D-, etc                  dorsal vertebrae 1-12

D5W, D10W, etc            dextrose 5% water, dextrose 10% water, etc

D&C                           dilatation and curettage

db                                decibel

Dent                            dental

Diab                            diabetic

Derm                           dermatology

DES                            diethylstilbestrol

DIC                             disseminated intravascular coagulation

DIFF                           differential blood count

dil.                               dilute

DIP                             distal interphalangeal

DISCH                        discharge

DJD                            degenerative joint disease

DKA                           diabetic ketoacidosis

DM                             diabetes mellitus

DNR                           do not resuscitate

DO                              distral occlusal surface of tooth

DOA                           dead on arrival

DOB                           date of birth

DOD                           mesial occlusal distal surface of tooth

DOE                            dyspnea on exertion

DP                               dorsalis pedis

DPT                            diptheria & tetanus toxoids with pertussis

dr                                 dram

D-Spine                       dorsal spine

DSA                            digital subtraction angiogram

DT’s                            delirium tremens

DTR                            deep tendon reflexes

DUB                            dysfunctional uterine bleeding

DVT                            deep vein thrombosis

DWI                            driving while intoxicated

Dx                               diagnosis

 

ECG                            electrocardiogram

ECT                            electrocenvulvise therapy

EECE-IOL                  extracapsular cataract extraction-intraocular lens

EEG                            electrencephalogram

EENT                          eyes, ears, nose and throat

EFF                             effective

e.g.                              for example

EGD                            esophagogastroduodenoscopy

EKG                            electrocardiogram

EMD                           electromechanical dissociation (asystole)

EMG                           elentrolyogram

Endo                            endodontia

ENG                            electronystagmography

ENT                            ears, nose and throat

ent.                              External Nutritional Therapy

EOM                           extra ocular movements

EOM                           extraocular muscle

EOMI                         extraoccular movements intact

EPS                             extrapyramidal symptoms

E-PAP                         expiratory positive airway pressure

ER                               emergency room

ERCP                          endoscopic retrograde cholangiopancreatography

ERT                            estrogen replacement therapy

ESR                            erythrocyte sedimentation rate

ESRD                         end stage renal disease

etio.                             etiology

ET                               educational therapy

ETOH                         ethyl alcohol

ETT                             endotrachial tube

ext.                              extremity

Ext                              extraction

EXU                            excretory urogram with post-voiding film

 

F                                  female

oF                                 fahrenheit

F.B.                             foreign body

FBS                             fasting blood sugar

Fdg                              feeding

Fe                                iron

FeSO4                         ferrous sulfate

FEV                             forced expiratory volume

FH                               family history

Fib                               fibrillation

FIO                             forced inspiratory O2

FRC                            functional residual capacity

fl.dr.                            fluid fram

fl.oz.                            fluid ounce

FSH                             follicle stimulating hormone

ft                                  feet/foot

FTA                             fluorescent treponemal antibody

FTA-ABS                    fluorescent treponemal antibody absorption test

FTI                              free thyroxin index

FTR                            failed to report

FTSG                          full thickness skin graft

F/U                              follow-up

FUO                            fever of undetermined origin

FVC                            forced vital capacity

FWB                           full weight bearing

Fx                                fracture

 

G6PD                          glucose-6-phosphate dehydrogenase

g                                  gram

G                                 gravida

GAF                            Global Assessment of Functioning

GATB                         General Apitude Test Battery

GB                              gallbladder

GBS                            gallbladder series

GC                              gonorrhea

GCE                            general conditioning exercise

GE                               gastroesophgel

GED                            general education development

GE junction                 gastroesophageal junction

GGTP                         gamma-glutamyl transferase

GI                                gastrointestinal

glob.                            globulin

gm                               gram

Gm/dl                          grams per deciliter

GMC                          General Medicine Clinic

gr.                                grain

GSW                           gunshot wound

gtt                                drop

gtts                              drops

GTT                            glucose tolerance test

G-tube             gastrostomy tube

GU                              genitourinary

GXT                            graded exercise test

 

H2O                            water

H2O2                          hydrogen peroxide

hr                                 hour

HA                              headache

HAV                            Hallux Adductus Valgus

HB                              housebound

HBP                            high blood pressure

H.C.                            Huntington’s Chorea

HCMI                         Homeless Chronically Mentally Ill

HCO3                         bicarbonate

Hct                              hematocrit

HDL                            high density lipoprotein

HEENT                       head, eyes, ears, nose, throat

Hgb                             hemoglobin

HgbA1c                       Hemoglobin A1c

HGSL                         Hygrade Squamous Epithelial Lesion

H&H                           hemoglobin and hematocrit

HIDA (scan)               hepatobiliary iminodiacetic acid

HIV                             human immune deficiency virus

HL                               hearing level

HLA B-27                   tissue typing for human leukocyte antigen

HM                             hand motion vision

HNI                             hospitalization not indicated

HNP                            herniated nucleus pulposus

H/O                             history of

HOB                           head of bed

H&P                            history and physical

HPF                             high powered field

HPI                             history of present illness

hr(s)                            hour(s)

HRT                            hormone replacement therapy

h.s.                              at bedtime

ht.                                height

HTLV-III                    human T-cell leukemia virus

HTN                            hypertension

HVD                           hypertensive cardivascular disease

HCVD                         hypertensive cardiovascular disease

HTL                            hearing threshold level

Hyst                            hysterectomy

Hx                               history

Hz                                Hertz, Frequency or cycles per second

 

I                                   iris

IBC                             iron binding capacity

IBW                            ideal body weight

ICA                             internal carotid artery

ICU                             Intensive Care Unit

I & D                          incision and drainage

IDDM                         insulin dependent diabetes mellitus

i.e.                               that is

IGT                             impaired glucose tolerance

IHD                             ischemic heart disease

IHSS                           idiopathic hypertrophic subaortic stenosis