14 10 acceptable abbreviations acronyms for...

14.10

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14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING

Page 2 of 21

3HC ACCEPTABLE INITIALS, ABBREVIATIONS, AND SYMBOLS FOR CHARTING

30 SEC STS 30 SECOND SIT TO STAND TEST

3HC Home Health and Hospice Care, Inc.

6MWD 6 MINUTE WALK DISTANCE

6MWT 6 MINUTE WALK TEST

A.D. auris dextra (right ear)

a/o as ordered

A/SE actions and side effects

A/T assess and teach

ABC SCALE ACTIVITY‐SPECIFIC BALANCE CONFIDENCE SCALE

abd abdomen,

ABD ABDUCTION (PT)

ABG arterial blood gas

AD assistive device

ADA American Diabetic Association

ADD ADDUCTION

ADL activities of daily living

adm admitted

admin administered

AFB acid‐fast bacillus

AFO ankle foot orthosis

AFP Alphafetoprotein

AIDS Acquired Immunodeficiency Syndrome

AIMS abnormal involuntary movements

AKA above‐the‐knee (amputation)

ALS Amyotrophic Lateral Sclerosis;

AM morning

AMA against medical advice

amb ambulate

AML Acute Myelocytic Leukemia

amt amount

ant anterior

AP apical pulse


Page 3 of 21

AP ankle pumps (PT)

approx approximately

appt appointment

APS Adult Protective Services

AROM active range of motion

ASA aspirin

ASCVD arteriosclerotic cardiovascular disease

ASD arterial septal defect

ASHD atherosclerotic heart disease

asst assistance

aud auditory

ausc auscultation

AV atrioventricular

ax axillary

B&B bowel and bladder

B/T between

BBS bilateral breath sounds

BBT basal body temperature

BCBS Blue Cross/Blue Shield

BCP birth control pills

BDF bilateral dorsi‐flexion

BE barium enema

BGM blood glucose monitor

bid twice a day

bili bilirubin

BJH Betsy Johnson Hospital

BKA below‐the‐knee (amputation)

bld blood

BLE both lower extremities

BM bowel movement

BMR basal metabolic rate

BP blood pressure

BPH benign prostatic hypertrophy

BR bedrest

BRP bathroom privileges


Page 4 of 21

BS bowel sounds, breath sounds, blood sugar

BSC bedside commode

BSN Bachelor of Science in Nursing

BSW Bachelor of Social Work

BTL bilateral tubal ligation

BUE bilateral upper extremities

BUN blood urea nitrogen

BX biopsy

C Centigrade, Celsius

C&S culture and sensitivity

C.C. chief complaint

c/o complain of

C1, C2, C3, etc. first cervical vertebra, second cervical, etc.

CA cancer, carcinoma

Ca calcium, cancer

CABG Coronary artery bypass graft

cap capsule, capillary

CAP/C Community Alternatives Program for Children

CAP/DA Community Alternatives Program for Disabled Adults

CAP/MR Community Alternatives Program for the Mentally Retarded

CATH catheter, catheterize

CBC complete blood count

CBG capillary blood glucose

CBS chronic brain syndrome

CCU Coronary Care Unit

CD Clinical Director

CDC Center for Disease Control, Child Development Center

CF cystic fibrosis

CG caregiver

CGA contact guard assist

CHD coronary heart disease

CHEM 12 sequential multiple analysis of 12 chemistry constituents

CHEM 7 sequential multiple analyzer with compound

chemo chemotherapy

CHF congestive heart failure


Page 5 of 21

chr chronic

CK check

Cl chloride

CLOF current level of function

cm centimeter

CM Case Manager

CMM Clinical Management Meeting

CMS Center for Medicare and Medicaid Services

CMV cytomegalovirus

CNA certified nursing assistant

CNS central nervous system

Co county

CO2 carbon dioxide

comp. comprehension

cont continue

conv. conversation

coord. coordination

COPD chronic obstructive pulmonary disease

COTA/L Certified Occupational Therapy Assistant/Licensed

CP cardiopulmonary

CP cerebral palsy

CPAP Continuous positive airway pressure

CPM Continuous passive motion

CPR cardiopulmonary resuscitation

creat creatinine

crit hematocrit

C‐sect Cesarean section

CSF cerebrospinal fluid

CT or CT scan computerized axial tomography scan

CVA cerebrovascular accident

CVD cardiovascular disease

CXR chest x‐ray

cysto cystoscopy

D dependent

D&C dilatation and curettage


Page 6 of 21

D&E dilatation and evacuation

D/C discharge, discontinue

D/T due to

D5W 5% dextrose in water

DAUG daughter

DEC Developmental Evaluation Clinic

Decub. decubitus

DEMO demonstrate

DEMOS demonstrations

dept department

DF dorsiflexion

DGI: DYNAMIC GAIT INDEX TEST

diff differential

DJD degenerative joint disease

DM diabetes mellitus

DME durable medical equipment

DNR do not resuscitate

DO Doctor of Osteopathy

DOA dead on arrival

DOB date of birth

doc document

DOE dyspnea on exertion

DPT diphtheria, pertussis, tetanus

Dr. doctor

DRG diagnostic‐related‐group

DSD dry sterile dressing

dsg dressing

DSS Department of Social Services

DTR deep tendon reflex

dtr (lowercase) daughter

DTs delirium tremens

DVT deep venous thrombosis

dx diagnosis

dz disease

E. coli Escheria Coli


Page 7 of 21

e.g. for example

E/SE effect and side effects

ea each

ECG, EKG electrocardiogram

ED emergency department

EDU education

EEG electroencephalogram

EENT eye, ear, nose and throat

ELIM elimination

elix elixir

EMER emergency

EMS emergency medical services

ENG English

ENT ear, nose and throat

ENVIR environment

EOB edge of bed

EOM extraocular movement

eos eosinophil

EP epidural

EQUIPM equipment

ER emergency room

ER external rotation (PT)

esp especially

ESRD end‐stage renal disease

et and

etc. and so on

etiol etiology

ETOH ethyl alcohol

eval evaluation

EX’S exercises

EXAC exacerbations

exam examination

exp expressive

expir expiration, expiratory

explap exploratory laparotomy


Page 8 of 21

Ext extension

ext./EXT external

F Fahrenheit

F/U follow‐up

FBS fasting blood sugar

FC Foley catheter

FDA Food and Drug Administration

Fe iron

FFST: FIVE TIME SIT TO STAND TEST

FHR fetal heart rate

FHT fetal heart tones

FICSIT Fraility And Injuries: Cooperative Studies Of Intervention Techniques (Tests Of Progressive Static Balance)

fl. oz fluid ounce

fld fluid

Flex Flexion

FMLA Family Medical Leave Act

FNP Family Nurse Practitioner

FOB foot of bed

Freq. frequency

FSBS finger stick blood sugar

ft foot, feet

FUO fever of unknown origin

FWB full weight bearing

Fx., fract. fracture

gal gallon

GDAU granddaughter

GI gastrointestinal

Gm, gm gram

GT gait training

GT/TR gait training

GTT glucose tolerance test

G‐Tube/GT gastrostomy tube

GU genitourinary

gyn gynecology


Page 9 of 21

H&H hemoglobin and hematocrit

H&P history and physical

H/O history of

H2O water

H2O2 hydrogen peroxide

HA headache

HB, Hgb hemoglobin

HBs Ag Hepatitis B surface antigen

HCG human chorionic gonadotrophin

HCl hydrochloric acid

HCT hematocrit

HCTZ hydrochlorithiazide

HCVD hypertensive cardiovascular disease

HEENT Head, eyes, ears, nose and throat

HEP home exercise program

Hg mercury

HHA Home Health Aide, Home Health Agency

HHA Hand held assistance (PT)

HHN Home Health Nurse

HI hearing impaired

HIV human immunodeficiency virus

HMO Health Maintenance Organization

HOB head of bed

HOH hard of hearing

HOH hand on hand (rehab)

Hosp/HOSP hospital

HR/R heart rate and rhythm

HS heel slide

HS ham set (rehab)

ht height

HT heel taps

HTN hypertension

Hwy highway

hx history

HYDRA hydration


Page 10 of 21

hyper above

hypo below

I independently, independent

I&D incision and drainage

I&O intake and output

i.e. that is

IADL independent activities of daily living

ICF intermediate care facility

ICP intracranial pressure

ICU Intensive Care Unit

ID identification/identify

IDDM insulin dependent diabetes mellitus

IDG Interdisciplinary Group

IM intramuscular

in inch

INC increase

IND independent

inf. infusion

inhal. inhalation

INJ injection

INR international ratio

Ins. insurance

inspir inspiration, inspiratory

instill. instillation

Instr. instruction

INT internal

INT/EXT internal/external

INTERACTS interactions

INTERVENT interventions

IOP intraocular pressure

IPPB intermittent positive pressure breathing

IQ Intelligence quotient

IR internal rotation

irr., irreg. irregular

ITC Interdisciplinary Team Conference


Page 11 of 21

IUD intrauterine device

IUGR intrauterine growth retardation

IV intravenous

IVF intravenous fluid

IVP IV push

IVT intravenous therapy

JMH Johnston Memorial Hospital

JVD jugular venous distention

K+ potassium

KAHC Kitty Askins Hospice Center

kg kilogram

L/S/T lying, sitting, standing

LA left atrium

lab laboratory

lang. language

lap laparotomy

LAQ long arc quad

lat lateral

lb. Pound

LBM loose bowel movement

LBP low back pain

LBQC large based quad cane

LD learning disability

LE lower extremity

Lg/LGE large

liq liquid

LLB long leg brace

LLE left lower extremity

LLL left lower lobe

LLQ left lower quadrant

LMH Lenoir Memorial Hospital

LMP last menstrual period

LOB loss of balance

LOC level of consciousness, loss of consciousness, laxative of choice

LP lumbar puncture


Page 12 of 21

LPN Licensed Practical Nurse

LPT Licensed Physical Therapist

LR lactated Ringer's

LRAD least restrictive assistive device

LUE left upper extremity

LUL left upper lobe

LUQ left upper quadrant

LVH left ventricular hypertrophy

lymph lymphocytes

lytes electrolytes

m meter

max maximum

MCD Medicaid

mcg microgram

MCH mean corpuscular hemoglobin

McK McKesson

MCL midclavicular

MCRA Medicare

MCV mean corpuscular volume

MD medical doctor

Meas. measure

Meds medications

mEq milliequivalent

Mg magnesium

mg. mgm milligram

MGMT management

MI myocardial infarction

MIN minimal

min minimum, minute

ml milliliter

mm millimeter

MMT manual muscle test

MOD BORG, BORG scale to show rate of perceived exertion

mod/MOD moderate

MOM milk of magnesia


Page 13 of 21

mono monocytes, mononucleosis

MR mentally retarded/medical record

MRSA Methacillin Resistant Staph Aureus

MS multiple sclerosis

MSDS material safety data sheet

MSS Medical Social Services

MSSP Master of Science, Speech Pathology

MSW Master of Social Work

MVA motor vehicle accident

MVI multivitamin

MVMT movement

MVP Mitral Valve Prolapse

N&V nausea and vomiting

N/A not applicable or not addressed

N/S normal saline

Na sodium

NA Nursing Assistant

NaCL Sodium Chloride

neg negative

neuro neurology

NG nasogastric

NGT nasogastric tube

NH3 ammonia

NHP nursing home placment

NIDDM noninsulin dependent diabetes mellitus

NKA no known allergies

No. number

noc night, at night

NOC Nurse On‐Call

norm. normal

NPI National Provider Identification Number

NPO nothing by mouth

NPU not picked up

nsg. nursing

NSR normal sinus rhythm


Page 14 of 21

NTG nitroglycerin

NWB non weight bearing

O2 oxygen

O2 sats Oxygen saturation

OA Osteoarthritis

OASIS Outcome Assessment and Information Set

OB obstetrics

obj object

OBS organic brain syndrome

occ occasional

OD overdose

oint ointment

OJ orange juice

OOB out of bed

OOP out of pocket

OP ophthalmic

Opth ophthalmology

OR operating room/by mouth/oral

Ortho; Orth orthopedic

OSHA Occupational Safety and Health Administration

OSTEO Osteoarthropathies

OT Occupational Therapy

OTC over the counter

OTR/L Occupational Therapist, Registered/Licensed

OX oximeter

Ox3 oriented to person, place, time

oz. ounce

P pulse

PA physician's assistant

PAC Port‐a‐Cath

PAP Papanicolaou [test]; peak airway pressure

PARA paralyzed

Pb lead

PBI protein bound iodine

PC personal care


Page 15 of 21

PCA personal care aide

PCMH Pitt County Memorial Hospital

pCO2 partial pressure of carbon dioxide

PDA patent ductus arteriosus

PDR Physician's Desk Reference

PE physical examination, pulmonary embolism

peds pediatrics

PEEP positive end‐expiratory pressure

PEG Percutaneous Endoscopic Gastrostomy

per by, through

PERF perform

PERLA pupils, equal and reactive to light and accommodation

PERRLA pupils, equal, round, reactive to light and accommodation

PF plantarflexion

pH hydrogen concentration

PICC peripherally inserted central catheter

PID pelvic inflammatory disease

PLOF/plof prior level of function

PM afternoon

PMH past medical history

PMM Professional Management Meeting

po/PO by mouth

POA power of attorney

POC Plan of Care

polys polymorphonuclear leukocytes

poplit popliteal

pos positive

post posterior, postvocalic (after vowel)

postop postoperative

POT plan of treatment

potent. potential

PP postprandial

PPD purified protein derivative

preop preoperative

prep preparation, prepare for


Page 16 of 21

PRES present

PRN whenever necessary, as needed

PRNT parent

PROB problem

PROF professional

PROM passive range of motion

protime prothrombin time

pt patient

PT physical therapy/prothrombin time

PT/CG patient/caregiver

PTA physical therapy assistant

PTT partial thromboplastin time

PV peripheral vascular

PVC premature ventricular contraction

PVD peripheral vascular disease

PVR post void residual

PWB partial weight bearing

q every

q am every morning

q2h, q3h, etc. every two hours, every three hours, etc.

QA quality assurance

QC quad cane

qid four times a day

QS quad set

R, rt. (R) right

R/O rule out

R/T reference to, related to

RA rheumatoid arthritis, right atrium

RBC red blood cell, red blood count

RBS random blood sugar

rd road

re regarding

recep receptive

REM rapid eye movement

REPS repetitions


Page 17 of 21

REQ MIN A requires minimal assistance

resp respiration, respiratory

Rh Rhesus factor

RH right hand

RHIA Registered Health Information Administrator

RHIT Registered Health Information Technician

RLE right lower extremity

RLL right lower lobe

RLQ right lower quadrant

RML right middle lobe

RN Registered Nurse

RNOC RN On‐Call

RNS request no service

ROM range of motion

RSC right subclavian

RT respiratory therapist, therapy

RTC return to clinic

RTO return to office

RUE right upper extremity

RUL right upper lobe

RUQ right upper quadrant

RVH right ventricular hypertrophy

RW rolling walker

Rx therapy, treatment, prescription

S sitting

s/p status/post

S/S, S&S signs and symptoms

S/SE symptoms/side effects

SA node sinus‐atrial node

SaO2 oxygen saturation in arterial blood

SAQ short arc quads

SASH Saline Administration Saline Heparin

SBA stand by assistance

SBA standby assist

SE side effects


Page 18 of 21

SEC secondary

sed rate sedimentation rate

SGOT serum glutamic oxaloacetic transaminase

SGPT serum glutamic pyruvic transaminase

SLB short leg brace

SLP Speech Language Pathologist

SLR straight leg raise

SMA12 sequential multiple analysis of 12 chemistry constituents

SMAC sequential multiple analyzer with compound

SN skilled nursing

SNF Skilled Nursing Facility

SNV Skilled Nursing Visit

SO4 sulfate

SOB shortness of breath

SOC start of care date

SP Speech Pathologist

SPA Spanish

SPC single point cane

spec. specimen

spon., spont spontaneous

SPOU spouse

SPT stand/pivot/transfer

SRMC Sampson Regional Medical Center

SS Social Security

SSE soap suds enema

ST, SP Tx speech therapy

STAT at once

stim stimulation

SUBQ subcutaneous

Sup Supervision, supervisory

SV supervisory visit

SVC superior vena cava

SW Social Worker

SWAL swallowing

Sx, sympt symptoms


Page 19 of 21

Syl. syllables

T&A tonsillectomy and adenoidectomy

T, temp temperature

T.O. telephone order

t/f transfer

T/F SPT transfer (stand, pivot, transfer)

tab tablet

TB tuberculosis

TBI traumatic brain injury

Tbsp tablespoon

TC&DB turn, cough and deep breathe

TD transdermal

TDWB touch down weight bearing

Tech. technique

Ther act Therapeutic activities

Ther ex therapeutic exercises

THR total hip replacement

TIA transient ischemic attack

tid, t.i.d. three times a day

TKR total knee replacement

tol. tolerates

TPR temperature, pulse and respirations

trach tracheostomy

TSA total shoulder arthroplasty

TSH thyroid stimulating hormone

TSM Dressing Transparent Semipermeable Membrane

tsp teaspoon

TT transfer training

TTB tub transfer bench

TTWB toe touch weight bearing

TUR transurethral resection

TURP transurethral resection prostate; Transurethal Prostectomy

TV tidal volume

Tx treatment

UA urinalysis


Page 20 of 21

UB upper body

UE upper extremities

UGI upper gastrointestinal

UKO unknown origin

umb umbilicus, umbilical

UNC University of North Carolina Chapel Hill

UR Utilization Review

URI upper respiratory infection

UTI urinary tract infection

VA Veteran's Administration/vaginal

VAD vascular access device

vag vaginal

VC/S AD verbal cues without assistive device

VCS verbal cues

VD venereal disease

Vent ventilator

via by way of

vit vitamin

VO verbal order

vol volume

VP venipuncture

VS vital signs

w/c wheelchair

w/d warm and dry

w/o without

w/p, WP whirlpool

WBAT weight bearing as tolerated

WBC white blood cells, white blood count

WC wound care

WFL within functional limits

WilMed Wilson Memorial Hospital

wk week

WMC Wake Medical Center

WMH Wayne Memorial Hospital

WND wound


Page 21 of 21

WNL within normal limits

wt. weight

x times

yr year

increase

increased

decreased

@ at

~ approximate

2 secondary to

° degree

‐ minus, negative

+ plus, positive

= equal to

Δ change

> greater than

< less than

♂ male

♀ female

# number, pounds

÷ divided by

% percent

& and

c with

p after

s without

14 10 acceptable abbreviations acronyms for...

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