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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
IM intramuscular
Imp impression
IMP impaction (tooth)
IMU Intermediate Medicine Unit
IMV intermittent (mechanical) mandatory ventilation
I&D incision & drainage
I&O intake and output
IO inferior oblique
IOP intraocular pressure
I-PAP inspiratory positive airway pressure
IPPB intermittent positive pressure breathing
IQ intelligence quotient
IR internal rotation
IT Incentive Therapy
IV intravenous
IVC intravenous cholangiogram
IVP intravenous pyelogram
IVPB intravenous piggy-back
JVD jugular venous distention
JVP jugular venous pressure
K kilo e.g., 64k, RAM
KCI potassium chloride
kg kilogram
KJ knee jerk
KT kinesiotherapy
Kt potassium
KUB kidneys, ureters and bladder
KVO keep vein open
L-1,L-2, etc. lumbar vertebrae, 1, 2, 3, etc. through 5
l liter
L left
La left atrail
Lap laparotomy
LAD left axis deviation
LAFB left anterior fascicular block
LAH left anterior hemiblock
lab laboratory
lat lateral
lb pound
LBBB left bundle branch block
LBP lower back pain
LCM left costal region
LDH lactic dehydrogenase
LDL low density lipoprotein
L-DOPA levadopamine
LE lower extremity
LES lower esophageal sphincter
LFT liver function test
lg large
LGI lower gastrointestinal
LGL Lown-Ganong-Levin Syndrome
LGSIL low grade squamous epithelial lesion
Ling lingual surface of tooth
LLE left lower extremity
LLL left lower lobe (lung)
LLQ left lower quadrant (abdomen)
LMD local medical doctor
LMP last menstrual period
LNMP last normal menstrual period
LOA leave of absence
LOC loss of consciousness
LOS length of stay
LP lumbar puncture
LPF low power field
LPFB left posterior fascicular block
LPH left posterior hemiblock
LPHB left posterior hernia block
LS lumbosacral
LSB left sternal border
L-Spine lumbar spine
LS Spine lumbosacral spine
LTC long term care
LTG long term goal
LUE left upper extremity
LUL left upper lobe (lung)
LUQ left upper quadrant
LVCD left ventricular conduction defect
LVCD + MI left ventricular conduction c infarct
LVH left ventricular hypertrophy
Lymph lymphocyte
M male
Mes mesial surface of tooth
m meter
M (encircled) murmur
M/M maxillary & mandibular
MAL midaxillary line
Malig malignant
Mammo mammogram
Mand mandibular
Max maxillary
Mcg microgram
MCH mean corpuscular hemoglobin
MCHC mean corpuscular hemoglobin concentration
MCL midclavicular line
MCP metacarpophalangeal
MCV mean corpuscular volume
MD Muscular Dystrophy
MED minimal brain dysfunction
Med medial
MEN (I,II,III) multiple endocrine neoplasia syndromes (Wemer, Sipple’s, etc)
Meq milliequivalent
Mets metastasis
MET metatarsal (specify area)
MHC Mental Hygiene Clinic
Mhz megahertz
MLB monaural loudness balance
Ml milliliter
MMPI Minnesota Multiphasic Personality Inventory
MMT manual muscle testing
Mm millimeter
MI myocardial infarction
mo(s) months
MAOD Medical Admitting Officer of the Day
MOD mesial-occlusal-surface of tooth
MOM Milk of Magnesia
MP metacarpophalangeal
MPJ metatarsal phalangeal joint
MR mitral regurgitation
MRI magnetic resonance imaging
MRSA Methicillin Resistant Staphylococcus Aureus
MS multiple sclerosis
MSL midsternal line
Ms morphine sulfate
MUGA (scan) multigated acquisition scan
MV millovolt
MVA motor vehicle accident
MVC maximum vital capacity
MVI multivitamins
MVV maximum ventilatory volume
N nausea
NA nasal antral
Na+ sodium
n/a not applicable
NAP nerve action potential
NAPA N-acetylprocaindmide
NaCI sodium chloride
NAD no appreciable disease
NBC nonbed care
NC normocephalic
NCV nerve conduction velocity
Ng nanogram
Neg negative
NG nasogastric
NGU nongonorrheal urethritis
NH nursing home
NHCU nursing home care unit
NID not in distress
NIDDM noninsulin dependent diabetes mellitus
NIVLS noninvasive vascular lab studies
Njcc near vision using Jaegger Chart with correction
NKA no known allergies
NKFA no known food allergies
nl. normal limits
NLP no light perception
NMI no middle initial
NOK next of kin
NP neuropsychiatric
NPH (insulin) Neutral Protamine Hagedorm (insulin)
NPN nonprotein nitrogen
NPO nothing by mouth
ns normal saline
NS nuclear sclerosis (of lens)
NSS normal saline solution
NSAID non-steroidal anti-inflammatory drugs
NSC non-service connected
NSR normal sinus rhythm
NST nutritional support team
NTG nitroglycerin
N&V nausea and vomiting
O2 oxygen
O objective
OA osteoarthritis
OBS organic brain syndrome
Occ occlusal surface of tooth
OCG oral cholecystogram
O&E observation and evaluation
OH oral hygiene
OL occlusive lingual surface of tooth
OMOL Objective Measurement of Observed Language
Oob out of bed
OPT outpatient treatment
OR operating room
ORIF open reduction and internal fixation
Ortho orthopedic
OS left eye
OU both eyes
Oz ounce
P para
/P mandibular partial denture
P/ maxillary partial denture
P/P maxillary & mandibular partial dentures
P1 first pulmonic sound
P2 second pulmonic sound
P&A phenol and alcohol procedure
PA posterior anterior
PAC premature atrial contractions
PAL posterioraxillary line
PAO2 partial pressure of oxygen in the alveoli
PaO2 partial pressure of oxygen in arterial blood
Pap papanicolaou test
PAR post anesthesia recovery
PARR post anesthesia recovery room
PAS progressive activity schedule
PAT paroxysmal atrial tachycardia
Path pathology
PBC prebed care
PBI protein bound iodine
PB/Max phonetically balanced/maximum
p.c. after meals
PCA pump patient controlled analgesic pump
PCN penicillin
PCO2 carbon dioxide pressure
PCV packed cell volume
PCWP pulmonary capillary wedge pressure
PE physical examination
PEEP positive and expiratory pressure
PEG percutaneous endoscopic gastrostomy
PERLA pupils equal, reactive to light and accommodation
PERRA pupils round, reactive to light
PET position emission tomography (scan)
PFT pulmonary function test
Pg pictogram
PH past history
PHD Public Health Department
PI present illness
PICA Porch Index of Communicative Abilities
PID pelvic inflammatory disease
PIP proximal interphalangeal
PM evening
PMD primary myocardial disease
PMI point of maximal impulse
PND paroxysmal noturnal dyspnea
POMR Problem Oriented Medical Record
Pod podiatry
p.o. per oral
PO2 oxygen pressure
Post posterior
post-op postoperative
POW prisoner-of-war
PPBS postprandial blood sugar
ppd pack(s) per day
PPD purified protein derivative (test for TB)
PPVT Peabody Picture Vocabulary Test
PRE-OP preoperative
PRN as needed
PRO protein
Prost prosthodontia
Prophy praphylaxis (oral)
PSA prostatic specific antigen
PSP phenolsulfonphthalein
PSYCH psychiatry
pt. patient
PT prothrombin time
PTA prior to admission
PTCA percutaneous transluminal coronary angioplasty
PTE pulmonary thromboembolism
PTPN peripheral total parenteral nutrition
PTSD post tramatic stress disorder
PTT partial thrombplastin time
PUD peptic ulcer disease
PVC premature ventricular contraction
PVD peripheral vascular disease
PVR post-voiding residual
PWB partial weight bearing
Px prognosis
Q every
Quad quadriceps
Quant quantity
q.a.c. before every meal
q.h. every _____ hours (blank represents no. of hours)
q.i.d. four times daily
q.ns quantity not sufficient
q.s. quantity sufficient
R right
RA rheumatoid arthritis
RAD right axis deviation
RAE right atrial enlargement
RAI radioactive iodine
RAO right atrial overload
Red reduction
RBBB right bundle branch block
RBC red blood cell count
RBT Rational Behavior Therapy
RCM right costal margin
RDA recommended daily dietary allowances
Rec recommendations
Resp respiration
RDW red cell distribution width
REST restorative (operative dentistry)
RF rheumatoid fever
RHD rheumatic heart disease
RIA radioimmunoassay
RLE right lower extremity
RLL right lower lobe (lung)
RLQ right lower quadrant (abdomen)
RML right middle lobe (lung)
RMS Rehabilitation Medicine Service
ROM range of motion
R/O rule out
RPR rapid plasma reagent
RR recovery room
Ret. Root Retained (dental) root
RRR regular rate rhythm
RS respiratory system
RSR Regular sinus rhythm
RTC return to clinic
RTW return to work
RU resin uptake
RUE right upper extremity
RUL right upper lobe (lung)
RUQ right upper quadrant (abdomen)
RV residual volume
RVCD+MI right ventricular conduction defect with infarct
RVH right ventricular hypertrophy
Rx prescription
S-1, etc sacral vertebrae 1-5
S1 first heart sound
S2 second heart sound
S3 third heart sound
S4 fourth heart sound
SA sinoatrial
SAO2 saturated arterial oxygen
S&A sugar and acetone
sat. saturated
SATP Substance Abuse Treatment Program
SBE subacute bacterial endocarditis
SBO small bowel obstruction
SC service-connected
SCD sequential compression device
Subq subcutaneous
SDS same day surgery
SD(s) speech discrimination (Score)
SDT speech detection threshold
SG swan-ganz
SGOT serum glutamic oxaloacetic transaminase
SGPT serum glutamic pyruvic transaminase
SI seriously ill
SIADH syndrome of inappropriate antidiuretic hormone
SICU surgical intensive care unit
SI joint sacroiliac joint
SIMV synchronized intermittent mandatory ventilation
Sibs siblings
SISI Short Increment Sensitivity Index
sl. sublingual
SL sensation level
SLE systemic lupus erythematosus
SLR straight leg raising
Sm small
SMA sequential multichannel analysis
SNS specialized nutritional support
SOAP Subjective, Objective, Assessment, Plan
SOAPIE SOAP plus intervention and evaluation
SOB shortness of breath
SOFAS Social and Occupational Functioning Assessment Scale
SOG special observation group
sol. solution
SPL sound pressure level
SP Status Post
sp.gr. specific gravity
Ss one half
SR standard release
s&s sign/symptoms
SS enema soapsuds enema
st soft tissue
Staph. staphylococcus
Stat immediately
STD sexually transmitted disease
STG short term goal
STS serologic test for syphilis
STSG split thickness skin graft
Strep streptococcus
SUI stress urinary incontinence
Surg surgery
SVC superior vena cava
SVT supraventricular tachycardia
Sx symptom
T temperature
T-1, etc. thoracic vertebrae 1-12
T-3 triiodothyronine
T4 thyroxine (thyroid test)
T&A Tonsillectomy & Adenoidectomy
TACHY tachycardia
TAH total abdominal hysterectomy
Tab tablet
TB tuberculosis
TBG thyroid binding globulin
TBP thyroxine binding protein
Tbsp tablespoon
TED(s) thromboembolic deterrent – stocking
TEE transesophageal echocardiogram
Temp temperature
TENS transcutaneous electrical nerve stimulation
THA total hip arthroplasty
TI tricuspid insufficiency
TIA transient ischemic attack
TIBC total iron binding capacity
t.i.d. three times daily
TKA total knee arthroplasty
TLC total lung capacity
TM tympanic membrane
TMJ temporal mandibular joint
TNTC too numerous to count
TNOMO used for staging cancer
T tumor
N nodes
O no node metastasis
M distant metastasis
O negative
TO telephone order
TP total protein
TPA tissue plasminogan activator
TPN total parental nutrition
TPR temperature, pulse, respiration
Trf transfer
Trich trichomonas
Trig triglycerides
T-Spine thoracic spine
T-Surg thoracic surgery
TS tricuspid stenosis
TSH thyroid stimulating hormone
tsp teaspoon
TU transurethral
TUR transurethral resection
TURBT transurethral resection of bladder tumor
TURP transurethral resection of prostate
TV tidal volume
TWE tap water enema
UA urinalysis
UCL uncomfortable loudness level
UE upper extremity
UGI upper gastrointestinal
UL upper lid
Unk unknown
UPJ ureteropelvic junction
URI upper respiratory infection
URTI upper respiratory tract infection
US ultrasound
UTI urinary tract infection
UV microvolt
UVJ ureterovestical junction
UVL ultraviolet light
V vomiting
VA Veterans Affairs
VC vital capacity
Vcc visual acuity with correction
VD venereal disease
VDRL venereal disease research laboratory test
VF visual fields
VFC ventricular fibrillary contraction
V Fib Ventricular Fibrillation
VH vaginal hysterectomy
VI Veterans Industries
VIS Visual Impairment Services
Vit vitamin
VMA vanillymandelic acid
VO verbal order
Vol volume
VP venous pressure
VPC ventricular premature contraction
VPD ventricular premature depolarization
Vph vision with pinhole
VQ ventilation perfusion
VSC ventricular septal defect
Vsc visual acuity without correction
V-surg vascular surgery
VT ventricular tachycardia
W white
WAIS Weschler Adult Intelligence
WBC white blood cell
WC wheelchair
WDWN well developed, well nourished
WD well developed
WN well nourished
WF white female
WM white male
wk(s) week(s)
WNL within normal limits
WPW Wolf Parkinson White Syndrome
WSK work sample kit
wt. weight
X-ray roentgen ray
YO year old
Yr year
ZOE zinc oxide eugenol
Symbols
& and
@ at
= equals
’ foot
” inch
+ positive
# pound
? questionable
2x twice
% percent
+/- plus/minus
Chemical Name Symbol
Actinium AC
Aluminum AL
Americium Am
Antimony Sb
Argon Ar
Arsenic As
Astatine At
Barium Ba
Berkelium Bk
Beryllium Be
Bismuth Bi
Boron B
Bromine Br
Cadmium Cd
Calcium Ca+
Californium Cf
Carbon C
Cerium Ce
Chlorine Cl
Chromium Cr
Cobalt Co
Cooper Cu
Curium Cm
Dysprosium Dy
Einsteinium Es
Erbium Er
Europium Eu
Fermium Fm
Fluorine F
Francium Fr
Chemical Name Symbol
Gadolinium Gd
Gallium Ga
Germanium Ge
Gold Au
Hafnium Hf
Hafnium Ha
Helium He
Holmium Ho
Hydrogen H
Iridium Ir
Iodine I
Iron Fe
Krypton Kr
Lanthanum La
Lawrencium Lw
Lead Pb
Lithium Li
Lutetium IU
Magnesium Mn
Mendelevium Md
Potassium K+
Rhenium Re
Rhodium Rh
Rubidium Rb
\Ruthenium Ru
Rutherfordium Rf
Samarium Sm
Scandium Sc
Selenium Se
Silicon Si
Chemical Name Symbol
Silver Ag
Sodium Na
Strontium Sr
Sulfur S
Tantalum Ta
Technetium Tc
Tellurium Te
Terbium Tb
Thallium Tl
Chemical Name Symbol
Thulium Tm
Tin Sn
Titanium TI
Tungsten W
Uranium U
Vanadium V
Xenon Xe
Zinc Zn
Zirconium Zr
PROHIBITED ABBREVIATIONS LIST
The Joint Commission has posted on its website – under FAQ for 2004 National Patient Safety Goals, the approved list of 9 dangerous abbreviations, acronyms and symbols that must be included on each accredited organization’s “Do not use” list: started January 1, 2004. They are:
A “minimum list” of dangerous abbreviations, acronyms, and symbols has been approved by JCAHO.
|
Abbreviations |
Potential Problem |
Preferred Term |
1. |
U (for unit) |
Mistaken as zero, four or cc |
Write “unit”
|
2. |
IU (for International unit) |
Mistaken as IV (intravenous or 10 (ten) |
Write “International unit”
|
3.
4. |
Q.D., Q.O.D
(Latin abbreviation for once daily and every other day) |
Mistaken for each other. The period after the Q can be mistaken for an “I” and the “O” can be mistaken for an “I” |
Write “daily” and “every other day” |
5.
6. |
Trailing Zero (X.O mg), Lack of Leading Zero (.X mg) |
Decimal point is missed |
Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)
|
7.
8.
9. |
MS, MSO4, or MgSO4 |
Confused for one another. Can mean morphine sulfate or magnesium sulfate |
Write “morphine sulfate” or “magnesium sulfate”
|
10. |
DC |
Premature discontinuation of medications when D/C (intended to mean “discharge” has been misinterpreted as “discontinued” when followed by a list of drugs.
|
Write “discharge” and “discontinue” |
11. |
Q6PM; q6AM, etc. |
Misread as every six hours
|
Write 6 PM “nightly” |
12 |
X3d |
Mistaken for three doses
|
Write “for 3 days” |
13. |
/ (slash mark) |
Misunderstood as the number 1 (“25 unit/10 units” read as “110” units.)
|
Do not use a slash mark to separate doses. Write “per”. |
#1-9 are mandated by JCAHO: These abbreviations are applicable whether there are “periods” between the letters or not. For example, “I.U.” cannot be an acceptable replacement for “IU”. In addition, the organization must have three (3) additional abbreviations on the list of its choosing.
#10-13 are mandated by CAVHCS.