Abbreviations Attachment 1

APPROVED SYMBOLS AND ABBREVIATIONS

ABBREVIATIONS (A) @ aa AA AAL Ab AB abd ABL AC acid phos ACM ACTH A&D ADD ADHD ADL ad lib adm admin AEB AED AF A-Fib AFB amal A/G AIDS AIMS AJ AKA alb alg Clinical Services Manual
Revised 4/07

at affected area Alcoholics Anonymous anterior axillary line antibiotic armband abdomen anticonvulsive blood level before meals acid phosphatase anticonvulsant medications adrenocorticotrophic hormone alcohol and drug attention deficit disorder attention deficit hyperactivity disorder activities of daily living at pleasure, at discretion, freely as desired admission administration as evidenced by automated external defibrillator African-American atrial fibrillation acid fast bacilli amalgam albumin globulin ratio acquired immune deficiency syndrome Abnormal Involuntary Movement Scale ankle jerk also known as albumin alginate

Abbreviations Attachment 1 alk phos ALL ALS ALT AMA AMH1 AMH2 AM A.M. amb AML amt ANC A&O AODM A-P A-P & Lat A&P APC appt Apr ARDS ARF AROM ASAP AMAP ARMC ASA ASD ASHD ASCVD Asst AST A/T Au AU Aug A/V Clinical Services Manual
Revised 4/07

alkaline phosphatase acute lymphocytic leukemia amyotrophic lateral sclerosis aspartate aminotransferase against medical advice Adult Mental Health 1 Adult Mental Health 2 before noon ambulatory acute myelogenous leukemia amount absolute neutrophil count alert and oriented adult onset diabetes mellitus anterioposterior anterioposterior and lateral auscultation and percussion atrial premature complexes appointment April adult respiratory distress syndrome acute renal failure active range of motion as soon as possible as much as possible Athens Regional Medical Center aspirin atrial septal defect arteriosclerotic heart disease arteriosclerotic cardiovascular disease assistant alanine aminotransferase activity therapy gold each ear August auditory / visual

Abbreviations Attachment 1 A-V AWOL (B) B Bact BAL baso BE BEAP Beh Sp Beh Tech B/F BHIS BHL BID bld bl cult BLT B/M BM BM/E BMR b/o BOP BP BPH BPRS BRBPR br sounds BR BRP BS BTL BTU BUN BW BWX BZD Clinical Services Manual
Revised 4/07

atrioventricular absent without leave buccal bacterium blood alcohol level basophil barium enema brainstem evoked auditory potential Behavior Specialist Behavior Technician black female Behavioral Health Information System Behavioral Health Link twice a day blood blood culture borderline tracing black male bowel movement bowel movement with enema basal metabolic rate because of blood, ova, parasites blood pressure benign prostate hypertrophy Brief Psychiatric Rating Scale bright red blood per rectum breath sounds bathroom bathroom privileges bowel sounds bilateral tubal ligation British Thermal Units blood urea nitrogen birth weight bite wing radiograph, bite wing x-ray benzodiazepine

Abbreviations Attachment 1 (C) C C1, C2, C3, etc. Ca CA CABG CAD CAL Calc cap cath CBC CBP CBZ cc CC CCT CDT CF CHD CHF CHI CHO Cl CL CLD cldy cm CM CMHC CN CNA CNS C/O col ct CO2 comp Clinical Services Manual
Revised 4/07

centigrade cervical vertebrae calcium carcinoma, cancer coronary artery bypass graft coronary artery disease calorie calculus capsule catheter complete blood count Comprehensive Behavior Plan carbamazepine (Tegretol) cubic centimeter chief complaint chronic catatonic type (schizophrenia) chronic disorganized type (schizophrenia) cystic fibrosis congenital heart disease congestive heart failure closed head injury carbohydrate chloride clinic complete lower denture cloudy centimeter continuous murmur Community Mental Health Center cranial nerve Certified Nursing Assistant central nervous system complaint of colony count carbon dioxide complete

Abbreviations Attachment 1 cont COPD CP&PD CPT CPR Cr CR CRF Cr Cl CRT CRU C&S CSH C-Section CSF CT CWR CUD CULD CUT CVA CXR CZP (D) D DBW D&C D/C DD DDEAMC DDS Dec Den Derm DFCS DI diff Clinical Services Manual
Revised 4/07

continue chronic obstructive pulmonary disease chest percussion and postural drainage chronic paranoid type (schizophrenia) cardiopulmonary resuscitation creatinine conditional release chronic renal failure creatinine clearance chronic residual type (schizophrenia) Consumer Resource Unit culture and sensitivity Central State Hospital cesarean cerebrospinal fluid computerized axial tomography cottage weight reduction complete upper denture complete upper and lower dentures chronic undifferentiated type cerebral vascular accident chest x-ray clonazepam (Klonopin)

day desirable body weight dilation and curettage discontinue developmental disabilities Dwight David Eisenhower Army Medical Center Doctor of Dental Surgery December dental dermatology Department of Family and Children Services diabetes insipidus differential

Abbreviations Attachment 1 DIP Disp dist DJD DLC DM DMD DNR DO D/O DOA DOB DON DPT DSM-IV D/T DTR DTs DVT DWR Dx (E) EAC ECHO ECT ECRH EDC EEG EENT eg EKG Elix EMG Endo EMT ENT EOE Clinical Services Manual
Revised 4/07

distal interphalangeal (joint) dispense (usually medication) distribution degenerative joint disease Developmental Learning Center diabetes mellitus Doctor of Dental Medicine do not resuscitate Doctor of Osteopathy disorder dead on arrival date of birth Director of Nursing Diphtheria and tetanus toxoids with pertussis Diagnostic and Statistical Manual Fourth Edition diphtheria/tetanus toxoid deep tendon reflexes delirium tremens deep vein thrombosis desirable weight range diagnosis

external auditory canal ultrasound cardiogram electroconvulsive therapy East Central Regional Hospital estimated date of confinement electroencephalogram eyes, ears, nose, and throat for example electrocardiogram elixir electromyogram endodontics Emergency Medical Technician ears, nose, and throat extraoral exam

Abbreviations Attachment 1 EOM EOMI eos epi EPS ER ESRD ESR esp EST et ETOH ext (F) F FB FBS&2hPP FBR FBS Feb FH fl tr fluoro FM FMX FOI FPD Fri FS FSH FSIQ FROM FST F/U FUO Fx female foreign body fasting blood sugar and 2-hour post prandial full body restraint fasting blood sugar February family history fluoride treatment fluoroscopy full mouth full mouth x-ray flight of ideas fixed partial denture (dental bridge) Friday fever scan (forehead thermometer) follicle stimulating hormone Full Scale Intelligence Quotient full range of motion Forensic Technician follow up fever of undetermined origin fracture extraocular movement (or muscle) EOM intact eosinophil epinephrine extrapyramidal symptoms emergency room end-stage renal disease erythrocyte sedimentation rate especially exercise stress test and alcohol extraction

Clinical Services Manual

Revised 4/07

Abbreviations Attachment 1 (G) GA GAD G6PD GB GBMI GBP GC GE GED GERD GFR GF GGT GI gm GM gm% GRH/A GRH/Atl GRH/Sav GSW GSSH GTube GTC gtt GTT GU Gyn general anesthesia generalized anxiety disorder glucose-6 phosphate dehydrogenase gallbladder guilty but mentally ill gabapentin (Neurontin) gonorrhea, gonococcus, gonococcal gastroesophageal general education development test gastroesophageal reflux disease glomerular filtration rate grandfather gamma glutamyl transpeptidase gastrointestinal gram grandmother grams per hundred milliliters of serum or blood as specified Georgia Regional Hospital at Augusta Georgia Regional Hospital at Atlanta Georgia Regional Hospital at Savannah gunshot wound Gracewood State School and Hospital gastrointestinal tube generalized tonic-clonic (seizures) drop glucose tolerance test genitourinary gynecology

(H) H H/A HBcAb HBsAb HBsAg HBP Clinical Services Manual

Revised 4/07

hour headache type B hepatitis core antibody type B hepatitis surface antibody type B hepatitis surface antigen high blood pressure

Abbreviations Attachment 1 HC Hct HCP HCTZ HEENT Hgb HHC HI histo HIV HJR h/o HO HOB Hosp H&P hpf HPI HRT HS HST HSV ht HTN Hx hyg H2O H202 (I) I I&D I&O IBW ICCE ICF/MR ICS I131 Clinical Services Manual
Revised 4/07

hydrocortisone hematocrit Health Care Plan hydrochlorothiazide head, eyes, ears, nose, and throat hemoglobin home health care homicidal ideation histoplasmosis human immunodeficiency virus hepatojugular reflux history of hold order head of bed hospital history and physical high powered field (used only in describing urine sediments) history of present illness hormone replacement therapy at bedtime Health Service Technician herpes simplex virus height hypertension history hygiene water hydrogen peroxide

incisal incision and drainage intake and output ideal body weight intracapsular cataract extraction Intermediate Care Facility/Mental Retardation intercostal space radioactive iodine

Abbreviations Attachment 1 ID IDT ie IM Imp INH In Pt IOE IOP IQ IRM ISP IST ITP IUD IUP IV IVDA IVF IVC IVP IWR (J) Jan J&J JMS JMS PN JODM July June (K) k kg KJ KUB KVO Clinical Services Manual
Revised 4/07

intradermal interdisciplinary team that is intramuscular impression isoniazid in patient intraoral exam intraocular pressure intelligence quotient (Caulk's) intermediate restorative material individual service plan incompetent to stand trial idiopathic thrombocytopenia purpura intrauterine device intrauterine pregnancy intravenous IV drug abuse intravenous fluids inferior vena cava intravenous pyelogram ideal weight range

January Johnson and Johnson (i.e., Baby Shampoo) Junior Medical Student Junior Medical Student progress note juvenile onset diabetes mellitus July June

potassium kilogram knee jerk kidney, ureter, bladder keep vein open

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Abbreviations Attachment 1 (L) L l L1, L2 L/A LA lab lac LAC LAD LAE LAH Lat lax lb LBBB LBP LCM LDH L-DOPA LE LE prep LFT lg LiCo3 lido Liq LJX LLE LLL LLQ LLSB LM LMD LMG LMP LN Clinical Services Manual
Revised 4/07

left (side) liter 1st lumbar vertebra, etc. living area long acting laboratory laceration living area clinic left axis deviation left atrial enlargement left atrial hypertrophy lateral laxative pound left bundle branch block lower back pain left costal margin lactate dehydrogenase levadopamine lower extremity lupus erythematosus cell preparation liver function tests large lithium carbonate lidocaine liquid lateral jaw x-ray left lower extremity left lower lobe - lung left lower quadrant - abdomen left lower sternal border land mark local medical doctor lamotrigine (Lamictal) last menstrual period lymph node

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Abbreviations Attachment 1 LOA LOC LOS LP LPN LPC LR L-S LSB LUE LUL LUQ LV LVE LVH LVT lymphs (M) m m Mar MAL mand May max MCG mcg MCH MCHC MCL MCP MCV MD MDE Med meds mEq Clinical Services Manual
Revised 4/07

looseness of association loss of consciousness line of sight lumbar puncture Licensed Practical Nurse Licensed Professional Counselor light reflex lumbosacral left sternal border left upper extremity left upper lobe - lung left upper quadrant - abdomen left ventricle left ventricle enlargement left ventricle hypertrophy levetiracetam (Keppra) lymphocytes

male murmur (cardiac) March midaxillary line mandibular May maximum Medical College of Georgia Hospital and Clinics micrograms mean corpuscular hemoglobin mean corpuscular hemoglobin concentration midclavicular line metacarpophalangeal (joint) mean corpuscular volume medical doctor major depressive episode medicine medication milliequivalent

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Abbreviations Attachment 1 mEq/l mg Mg mg% MGF MGM MH MHC MI MIC Misc ml mm mM MMG MMPI MMR MMSE mn mo m/o mos MOD MOM Mon MP MR MRE MRI MRSA MSE MSL MTP joint MTP MVA MVP MX milliequivalents per liter milligram magnesium milligrams per hundred milliliter of serum or blood maternal grandfather maternal grandmother mental health mental health center myocardial infarction minimum inhibitory concentrations miscellaneous milliliter or milliliters millimeter millimole mammogram Minnesota Multiphasic Personality Inventory measles/mumps/rubella Mini-Mental Status Exam midnight month month old months Medical Officer of the Day milk of magnesia Monday mouth prop mental retardation most recent episode Magnetic Resonance Imaging methicillin resistant staph aureus mental status exam midsternal line metatarsophalangeal joint minor treatment protocol motor vehicle accident mitral valve prolapse maxillary

Clinical Services Manual

Revised 4/07

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Abbreviations Attachment 1 (N) NAD N/A NA Na neg NeuroSurg Neuro NG NGRI NH nl NKA NKDA noc NOS N20/02 Nov NPN NPO NS NSAID NSDO NSR NSVD N/V N/V/D NWGRH (O) O , O2 O2 cap O2Sat OB obl obs Clinical Services Manual
Revised 4/07

no acute distress not applicable Nurse Administrator sodium negative neurosurgery neurology nasogastric not guilty by reason of insanity nursing home normal no known allergies no known drug allergies night not otherwise specified nitrous oxide and oxygen November nonprotein nitrogen nothing by mouth normal saline nonsteroidal anti-inflammatory drug neurosurgery danger orders normal sinus rhythm normal spontaneous vaginal delivery nausea and vomiting nausea, vomiting and diarrhea Northwest Georgia Regional Hospital-Rome

occlusal (surface of tooth) none oxygen oxygen capacity oxygen saturation obstetrics oblique observation

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Abbreviations Attachment 1 OCD OCBZ Oct OCV OD ODD OE OH OHD OM OOB Op Out Pt OPC OPV OR OTR Ortho OS OU OTC O/T oz (P) p P P2 PA P-A PA-C PAL PANSS PAP PAT path PAX Clinical Services Manual
Revised 4/07

obsessive compulsive disorder oxycarbazepine (Trileptal) October off campus right eye oppositional defiant disorder otitis externa oral hygiene organic heart disease otitis media out of bed operation outpatient outpatient clinic oral polio vaccine operating room Occupational Therapist, Registered orthopedic left eye both eyes over the counter occupational therapy ounce

after pulse pulmonic second sound Physicians Assistant posteroanterior Physicians Assistant - Certified posterior axillary line Positive and Negative Syndrome Scale papanicolaou's smear paroxysmal atrial tachycardia pathology periapical x-ray

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Abbreviations Attachment 1 PB PBI PC PCN PCH PCV PDA PDL PE PEG PEJ per perio PERL PERRLA PFE PFM PGF PGM pH PH PHR phos PI PID PIP PJC PKU pl ct PM PMH PMI PMS PND PO polys post Post-op Clinical Services Manual
Revised 4/07

phenobarbital protein bound iodine after meals, post prandial penicillin personal care home packed cell volume patient ductus arteriostosis periodontal ligament physical examination percutaneous gastrostomy percutaneous jejunostony through or by periodontal pupils equal and reactive to light pupils equal, round, reactive to light and accommodation Patient & Family Education porcelain fused to metal (crown) paternal grandfather paternal grandmother hydrogen ion concentration past history periodic health review phosphorus pulmonary insufficiency pelvic inflammatory disease proximal interphalangeal (joint) porcelain jacket crown phenylketonuria platelet count afternoon past medical history plea of mental incompetence premenstrual syndrome paroxysmal nocturnal dyspnea by mouth polymorphonuclear leucocytes (neutrophils) after postoperative

16

Abbreviations Attachment 1 PPD PR PPRG PPVT-R pre-op prep PRN Prog PROM Prophy psych PSA PT P/T pt PTA PTE PTN PTSD PTT PUD PUD w/GOO PVC PVD (Q) Q QAM Q(x)H QH QHS QID QMRP QPM QSHIFT (R) R Clinical Services Manual
Revised 4/07

purified protein derivative per rectum Psychiatric Psychoeducational Rehabilitation Group Peabody Picture Vocabulary Test-Revised pre-operative prepare for, preparation for as necessary, as needed prognosis passive range of motion dental prophylaxis psychiatric prostate specific antigen prothrombin time physical therapy patient prior to admission pretrial evaluation phenytoin (Dilantin) posttraumatic stress disorder partial thromboplastin time peptic ulcer disease peptic ulcer disease with gastric outlet obstruction premature ventricular contractions peripheral vascular disease

every; each every morning every (x) hours every hour every night at bedtime four times per day Qualified Mental Retardation Professional every afternoon every shift

right

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Abbreviations Attachment 1 RA RAD RAE RAH RAN RBBB RBC RBI RCM RCSD RCT RDH re readm rehab resp retic(s) RF Rh RHD RLE RLL RLQ RML RN R/O ROM ROS RPD RPR RR RRR R/T RTC RUE RUL RUQ RV Clinical Services Manual
Revised 4/07

rheumatoid arthritis right axis deviation right atrial enlargement right atrial hypertrophy resident admission note right bundle branch block red blood cell rubber base impression right costal margin Richmond County Sheriffs Department root canal therapy Registered Dental Hygienist regarding readmission rehabilitation respiration reticulocyte(s) rheumatoid factor rhesus blood factor rheumatic heart disease right lower extremity right lower lobe right lower quadrant right middle lobe lung Registered Nurse rule out range of movement review of systems removable partial denture rapid plasma reagent respiratory rate regular rate and rhythm related to return to clinic right upper extremity right upper lobe - lung right upper quadrant right ventricle

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Abbreviations Attachment 1 RVE RVH Rx (S) S S1 & S2 S3 & S4 Sz D/O Sat SBE SC Anemia SC Trait SE sed segs SEM Sept SGOT SGPT SH SHAPA SI SIADH SIB sib(s) sig: SI joint SI/HI sl SLE SLH SLR sm S-M SMS SNF SOAP (for progress notes) Clinical Services Manual
Revised 4/07

right ventricular enlargement right ventricular hypertrophy prescription, treatment

sign first and second heart sounds heart sounds (physiological) seizure disorder Saturday subacute bacterial endocarditis sickle cell anemia sickle cell trait side effects sedation segmented neutrophils systolic ejection murmur September serum glutamic oxaloacetic transaminase serum glutamic pyruvic transaminase social history Social History and Psychosocial Assessment suicidal ideation inappropriate secretion of antidiuretic hormone self-injurious behavior sibling(s) directions for use, label sacroiliac joint suicidal/homicidal ideation slight; slightly systemic lupus erythematous supportive living home straight leg raise small sensorimotor senior medical student Skilled Nursing Facility Subjective, Objective, Assessment, Plan

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Abbreviations Attachment 1 SOB SOC soln SOM SP S/P SPF sp gr SQ SS SSC SSD ss enema SSI Staph STAT STD Strep subg Sun Supp Surg susp SVT SWSH S/Sx Sx Sz SZAF (T) T T1, T2, etc. T/A T&A TAC TAT tab or tabs Clinical Services Manual
Revised 4/07

shortness of breath social solution serous otitis media suicide precaution(s) status-post sun protection factor specific gravity subcutaneous Social Security stainless steel crown Social Security Disability soapsuds enema supplemental security income staphylococcus immediately; at once sexually transmitted disease streptococcus subgingival Sunday suppository surgery; surgical suspension supra-ventricular tachycardia Southwestern State Hospital Thomasville signs/symptoms symptoms seizure schizoaffective

temperature 1st thoracic vertebra, etc. tooth ache tonsillectomy and adenoidectomy triamcinolone cream Thematic Apperception Test tablet (tablets)

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Abbreviations Attachment 1 TAH TAH & BSO TB Tbsp Td TD Teeth, identification of: Permanent # 1-16 17-32 Primary A-J K-T beginning with the upper right permanent 3rd molar and proceeding to the upper left permanent 3rd molar beginning with the lower left permanent 3rd molar and proceeding to the lower right permanent 3rd molar beginning with the upper right primary 2nd molar and proceeding to the upper left primary 2nd molar beginning with the lower left primary 2nd molar and proceeding to the lower right primary 2nd molar temp Temp Flg TFT TGB Thurs TIA TID T-L TL TLC TM TMJ TOF Toxo trach Trich TPM TPR tsp TT Tues TURP Clinical Services Manual
Revised 4/07

total abdominal hysterectomy total abdominal hysterectomy and bilateral salpingo oophorectomy tuberculosis tablespoon tetanus/diptheria toxoid tardive dyskinesia

temporary temporary filling thyroid function test tiagabine (Gabatril) Thursday transient ischemic attack three times daily thoracolumbar temporary leave tender loving care tympanic membrane temporomandibular joint tetralogy of fallot toxoplasmosis tracheostomy trichomonas topiramate (Topamax) temperature, pulse, respiration teaspoon tetanus toxoid Tuesday transurethral resection of prostate

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Abbreviations Attachment 1 TV TVH tx tx plan (U) UA UBR UDS UE UGI UGI w/SBFT UH UHBH UHER UP URI US USP UTI UV (V) VA V/A VAMC VCU VD VDO VDR VDRL VEP Vit Vol VO VPA VPC V-P Clinical Services Manual
Revised 4/07

trial visit total vaginal hysterectomy treatment treatment plan

urinalysis upper body restraints urine drug screen upper extremity upper gastrointestinal upper gastrointestinal series with small bowel follow through University Hospital University Hospital Behavioral Health University Hospital Emergency Room ureteropelvic upper respiratory infection ultra-sound United States Pharmacopoeia urinary tract infection ultraviolet

Veterans Administration visual acuity Veterans Administration Medical Center voiding cystourethrogram venereal disease vertical dimension of occlusion vertical dime venereal disease research laboratory visual evoked potential vitamin when followed by a specific letter, i.e., Vit. A volume verbal order valproic acid ventricular premature complexes ventriculo-peritoneal (shunt)

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Abbreviations Attachment 1 VRE VS VSD VSS V Tach (W) w/ WAIS-R WBC w/c WCGRH WD WD/WN Wed W/F W/M WN WNL w/o WPW Syndrome wt WTR (X) X (Y) y/o yr(s) (Z) ZOE ZSM zinc oxide and eugenol zonisamide (Zonegran) SYMBOLS o Clinical Services Manual
Revised 4/07

vancomycin resistant enterococcus vital signs ventricular septal defect vital signs stable ventricular tachycardia

with Wechsler Adult Intelligence Scale-Revised white blood count wheelchair West Central Georgia Regional Hospital - Columbus well-developed well-developed and well-nourished Wednesday white female white male well-nourished within normal limits without Wolff-Parkinson-White Syndrome weight within therapeutic range

times, i.e., X2 = 2 times

year old year(s)

degree

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Abbreviations Attachment 1 c s negative with; together without increase decrease positive less than less than or equal to greater than - use greater than greater than or equal to separates two doses or indicates per as in 5X/D= five times per day except for; with the exception of equal to; equals delta (change) primary secondary check recheck questionable and at therefore

+
< < > > / (slash mark) x = 1o 2o re ? & @ ...

Clinical Services Manual

Revised 4/07

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