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