Home Health and Hospice Care, Inc.

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTING

PURPOSE: To provide a standardized method of uniform documentation in the health record to promote effective communication throughout the agency and for other healthcare providers.

PROCEDURE:

Note: Many of the attached abbreviations are not appropriate for use in the electronic record. Staff should not use symbolic abbreviations (ex., parentheses (), semi-colon ; or quotes “ ”) in Horizon HomeCare EHR.

1. Whenever information is placed within the record and a symbol or abbreviation is utilized, staff must use only those abbreviations and symbols that have been approved as accepted.

Effective Date: July 1994Review Date: July 1999, August 2001, March 2003, September 2005, December

2006, June 2010Revision Date: July 1995, June 1996, June 1997, July 1998, September 1999,

September 2000, July 2004, February 2007, April 2007, June 2007, December 2008, September 2011, June 2012, October 2012, December 2013

Reviewed By: Kathryn Albritton, RHIA; Director of Professional Support ServicesMeta Michelle Weeks, Nurse Mentor/PI Analyst; Sandra Pate RN BSN CRNI®, Education Manager

Approved by:

VP of Clinical Services Date

Page 1 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 2

3HCACCEPTABLE INITIALS, ABBREVIATIONS, AND SYMBOLS FOR CHARTING

Unapproved Abbreviations Accepted Changes1. qd daily2. cc ml3. MS morphine4. MSO morphine5. u unit6. IU international unit7. MgSO magnesium8. QOD every other day9. X.0 mg Xmg10. .X mg 0.Xmg11. A.U. both ears12. µg mcg

30 SEC STS 30 SECOND SIT TO STAND TEST3HC Home Health and Hospice Care, Inc.6MWD 6 MINUTE WALK DISTANCE6MWT 6 MINUTE WALK TESTA/O Alert and orientedA/SE actions and side effectsA/T assess and teachABC SCALE ACTIVITY-SPECIFIC BALANCE CONFIDENCE SCALEABD abdomen, ABD ABDUCTION (PT)ABG arterial blood gasAD assistive deviceADA American Diabetic AssociationADD ADDUCTIONADL activities of daily livingadm admittedadmin administeredAFB acid-fast bacillusAFO ankle foot orthosisAFP AlphafetoproteinAIDS Acquired Immunodeficiency Syndrome

Page 2 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 3

AIMS abnormal involuntary movementsAKA above-the-knee (amputation)ALS Amyotrophic Lateral Sclerosis;AM morningAMA against medical adviceamb ambulateAML Acute Myelocytic Leukemiaamt amountant anteriorAP apical pulseAP ankle pumps (PT)approx approximatelyappt appointmentAPS Adult Protective Services AROM active range of motionASA aspirinASCVD arteriosclerotic cardiovascular diseaseASD arterial septal defectASHD atherosclerotic heart diseaseasst assistanceaud auditoryausc auscultationAV atrioventricularax axillaryB&B bowel and bladderB/T betweenBBS bilateral breath soundsBBT basal body temperatureBCBS Blue Cross/Blue ShieldBCP birth control pillsBDF bilateral dorsi-flexionBE barium enemaBGM blood glucose monitorbili bilirubinBJH Betsy Johnson Hospital

Page 3 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 4

BKA below-the-knee (amputation)bld bloodBLE both lower extremitiesBM bowel movementBMR basal metabolic rateBP blood pressureBPH benign prostatic hypertrophyBR bedrestBRP bathroom privilegesBS bowel sounds, breath sounds, blood sugarBSC bedside commodeBSN Bachelor of Science in NursingBSW Bachelor of Social WorkBTL bilateral tubal ligationBUE bilateral upper extremitiesBUN blood urea nitrogenBX biopsyC Centigrade, CelsiusC&S culture and sensitivityC.C. chief complaintc/o complain ofC1, C2, C3, etc. first cervical vertebra, second cervical, etc.CA cancer, carcinomaCa calcium, cancerCABG Coronary artery bypass graftCAP/C Community Alternatives Program for ChildrenCAP/DA Community Alternatives Program for Disabled AdultsCAP/MR Community Alternatives Program for the Mentally RetardedCATH catheter, catheterizeCBC complete blood countCBG capillary blood glucoseCBS chronic brain syndromeCCU Coronary Care UnitCD Clinical DirectorCDC Center for Disease Control, Child Development Center

Page 4 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 5

CF cystic fibrosisCG caregiverCGA contact guard assistCHD coronary heart diseaseCHEM 12 sequential multiple analysis of 12 chemistry constituentsCHEM 7 sequential multiple analyzer with compoundchemo chemotherapyCHF congestive heart failurechr chronicCK checkCl chlorideCLOF current level of functioncm centimeterCM Case ManagerCMS Center for Medicare and Medicaid ServicesCMV cytomegalovirus CNS central nervous systemCO2 carbon dioxidecomp. comprehensioncont continueconv. conversationcoord. coordinationCOPD chronic obstructive pulmonary diseaseCOTA/L Certified Occupational Therapy Assistant/LicensedCP cardiopulmonaryCP cerebral palsyCPAP Continuous positive airway pressureCPM Continuous passive motionCPR cardiopulmonary resuscitationcreat creatinineC-sect Cesarean sectionCSF cerebrospinal fluidCT or CT scan computerized axial tomography scanCVA cerebrovascular accidentCVD cardiovascular disease

Page 5 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 6

CXR chest x-raycysto cystoscopyD dependentD&C dilatation and curettageD&E dilatation and evacuationD/C discharge, discontinueD/T due toD5W 5% dextrose in waterDAUG daughterDEC Developmental Evaluation ClinicDEMO demonstrateDEMOS demonstrationsDF dorsiflexionDGI: DYNAMIC GAIT INDEX TESTdiff differentialDJD degenerative joint diseaseDM diabetes mellitusDME durable medical equipmentDNR do not resuscitateDO Doctor of OsteopathyDOA dead on arrivalDOB date of birthdoc documentDOE dyspnea on exertionDPT diphtheria, pertussis, tetanusDr. doctorDRG diagnostic-related-groupDSD dry sterile dressingdsg dressingDSS Department of Social ServicesDTR deep tendon reflexdtr (lowercase) daughterDTs delirium tremensDVT deep venous thrombosisdx diagnosis

Page 6 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 7

dz diseaseE. coli Escheria Colie.g. for exampleE/SE effect and side effectsea eachECG, EKG electrocardiogramED emergency departmentEDU educationEEG electroencephalogramEENT eye, ear, nose and throatELIM eliminationelix elixirEMER emergencyEMS emergency medical servicesENG EnglishENT ear, nose and throatENVIR environmentEOB edge of bedEOM extraocular movementeos eosinophilEP epiduralEQUIPM equipmentER emergency roomER external rotation (PT)esp especiallyESRD end-stage renal diseaseet andetc. and so onetiol etiologyETOH ethyl alcoholETS Endo Tracheal Suctioneval evaluationEX’S exercisesEXAC exacerbationsexam examination

Page 7 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 8

exp expressiveexpir expiration, expiratoryexplap exploratory laparotomyExt extensionext./EXT externalF FahrenheitF/U follow-upFBS fasting blood sugarFC Foley catheterFDA Food and Drug AdministrationFe ironFFST: FIVE TIME SIT TO STAND TESTFHR fetal heart rateFHT fetal heart tonesFICSIT Fraility And Injuries: Cooperative Studies Of Intervention Techniques

(Tests Of Progressive Static Balance)fl. oz fluid ouncefld fluidFlex FlexionFMLA Family Medical Leave ActFNP Family Nurse PractitionerFOB foot of bedFreq. frequencyFSBS finger stick blood sugarft foot, feetFUO fever of unknown originFWB full weight bearingFx., fract. fracturegal gallonGDAU granddaughterGI gastrointestinalGm, gm gramGT gait GT/TR gait trainingGTT glucose tolerance testG-Tube/GT gastrostomy tube

Page 8 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 9

GU genitourinarygyn gynecologyH&H hemoglobin and hematocritH&P history and physicalH/O history ofH2O waterH2O2 hydrogen peroxideHA headacheHB, Hgb hemoglobinHBs Ag Hepatitis B surface antigenHCG human chorionic gonadotrophinHCl hydrochloric acidHCT hematocritHCTZ hydrochlorithiazideHCVD hypertensive cardiovascular diseaseHEENT Head, eyes, ears, nose and throatHEP home exercise programHg mercuryHHA Home Health Aide, Home Health AgencyHHA Hand held assistance (PT)HHN Home Health NurseHI hearing impairedHIV human immunodeficiency virusHMO Health Maintenance OrganizationHOB head of bedHOH hard of hearingHOH hand on hand (rehab)Hosp/HOSP hospitalHR/R heart rate and rhythmHS heel slideHS ham set (rehab)ht heightHT heel tapsHTN hypertensionHwy highway

Page 9 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 10

hx historyHYDRA hydrationhyper abovehypo belowI independently, independentI&D incision and drainageI&O intake and outputi.e. that isIADL independent activities of daily livingICF intermediate care facilityICP intracranial pressureICU Intensive Care UnitID identification/identifyIDDM insulin dependent diabetes mellitusIDG Interdisciplinary GroupIM intramuscularin inchINC increaseIND independentinf. infusioninhal. inhalationINJ injectionINR international ratioIns. insuranceinspir inspiration, inspiratoryinstill. instillationInstr. instructionINT internalINT/EXT internal/externalINTERACTS interactionsINTERVENT interventionsIOP intraocular pressureIPPB intermittent positive pressure breathingIQ Intelligence quotientIR internal rotation

Page 10 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 11

irr., irreg. irregularITC Interdisciplinary Team ConferenceIV intravenousIVF intravenous fluidIVP IV pushIVT intravenous therapyJMH Johnston Memorial HospitalJVD jugular venous distentionK+ potassiumKAHC Kitty Askins Hospice Centerkg kilogramL/S/ST lying, sitting, standingLA left atriumlab laboratorylang. languagelap laparotomyLAQ long arc quadlat laterallb. PoundLBM loose bowel movementLBP low back painLBQC large based quad caneLD learning disabilityLE lower extremityLg/LGE largeliq liquidLLB long leg braceLLE left lower extremityLLL left lower lobeLLQ left lower quadrantLMH Lenoir Memorial HospitalLMP last menstrual periodLOB loss of balanceLOC level of consciousness, loss of consciousness, laxative of choiceLP lumbar puncture

Page 11 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 12

LPN Licensed Practical NurseLPT Licensed Physical TherapistLR lactated Ringer'sLRAD least restrictive assistive deviceLUE left upper extremityLUL left upper lobeLUQ left upper quadrantLVH left ventricular hypertrophylymph lymphocyteslytes electrolytesm metermax maximumMCD Medicaidmcg microgramMCH mean corpuscular hemoglobinMcK McKessonMCL midclavicularMCRA MedicareMCV mean corpuscular volumeMD medical doctorMeas. measureMeds medicationsmEq milliequivalentMg magnesiummg. mgm milligramMGMT managementMI myocardial infarctionMIN minimalmin minimum, minuteml millilitermm millimeterMMT manual muscle testMOD BORG, BORG scale to show rate of perceived exertionmod/MOD moderateMOM milk of magnesia

Page 12 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 13

mono monocytes, mononucleosisMR mentally retarded/medical recordMRSA Methacillin Resistant Staph AureusMS multiple sclerosisMSDS material safety data sheetMSS Medical Social ServicesMSSP Master of Science, Speech PathologyMSW Master of Social WorkMVA motor vehicle accidentMVI multivitaminMVMT movementMVP Mitral Valve ProlapseN&V nausea and vomitingN/A not applicable or not addressedN/S normal salineNa sodiumNA Nursing AssistantNaCL Sodium ChlorideNAD no acute distressneg negativeneuro neurologyNG nasogastricNGT nasogastric tubeNH3 ammoniaNHP nursing home placmentNIDDM noninsulin dependent diabetes mellitusNKA no known allergiesNo. numbernoc night, at nightNOC Nurse On-Callnorm. normalNPI National Provider Identification NumberNPO nothing by mouthNPU not picked upnsg. nursing

Page 13 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 14

NSR normal sinus rhythmNTG nitroglycerinNWB non weight bearingO2 oxygenO2 sats Oxygen saturationOA OsteoarthritisOASIS Outcome Assessment and Information SetOB obstetricsobj objectOBS organic brain syndromeocc occasionalOD overdoseoint ointmentOJ orange juiceOOB out of bedOOP out of pocketOP ophthalmicOpth ophthalmologyOR operating room/by mouth/oralOrtho; Orth orthopedicOSHA Occupational Safety and Health AdministrationOSTEO OsteoarthropathiesOT Occupational TherapyOTC over the counterOTR/L Occupational Therapist, Registered/LicensedOX oximeterOx3 oriented to person, place, timeoz. ounceP pulsePA physician's assistantPAC Port-a-CathPAP Papanicolaou [test]; peak airway pressurePARA paralyzedPb leadPBI protein bound iodine

Page 14 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 15

PC personal carePCA personal care aidePCMH Pitt County Memorial HospitalpCO2 partial pressure of carbon dioxidePDA patent ductus arteriosusPDR Physician's Desk ReferencePE physical examination, pulmonary embolismpeds pediatricsPEEP positive end-expiratory pressurePEG Percutaneous Endoscopic Gastrostomyper by, throughPERF performPERLA pupils, equal and reactive to light and accommodationPERRLA pupils, equal, round, reactive to light and accommodationPF plantarflexionpH hydrogen concentrationPICC peripherally inserted central catheterPID pelvic inflammatory diseasePLOF/plof prior level of functionPM afternoonPMH past medical historyPMM Professional Management MeetingPNT/pnt patientpo/PO by mouthPOA power of attorneyPOC Plan of Carepolys polymorphonuclear leukocytespoplit poplitealpos positivepost posterior, postvocalic (after vowel)postop postoperativePOT plan of treatmentpotent. potentialPP postprandialPPD purified protein derivative

Page 15 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 16

preop preoperativeprep preparation, prepare forPRES presentPRN whenever necessary, as neededPRNT parentPROB problemPROF professionalPROM passive range of motionPT physical therapyPT/CG patient/caregiverPT/INR prothrombin time/international normalized ratioPTA physical therapy assistantPTT partial thromboplastin timePV peripheral vascularPVC premature ventricular contractionPVD peripheral vascular diseasePVR post void residualPWB partial weight bearingq everyq am every morningq2h, q3h, etc. every two hours, every three hours, etc.QA quality assuranceQC quad caneqid four times a dayQS quad setR, rt. (R) rightR/O rule outR/T reference to, related toRA rheumatoid arthritis, right atriumRBC red blood cell, red blood countRBS random blood sugarrd roadre regardingrecep receptiveREM rapid eye movement

Page 16 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 17

REPS repetitionsREQ MIN A requires minimal assistanceresp respiration, respiratoryRh Rhesus factorRH right handRHIA Registered Health Information AdministratorRHIT Registered Health Information TechnicianRLE right lower extremityRLL right lower lobeRLQ right lower quadrantRML right middle lobeRN Registered NurseRNOC RN On-CallRNS request no serviceROM range of motionRSC right subclavianRT respiratory therapist, therapyRTC return to clinicRTO return to officeRUE right upper extremityRUL right upper lobeRUQ right upper quadrantRVH right ventricular hypertrophyRW rolling walkerRx therapy, treatment, prescriptionS sittings/p status/postS/S, S&S signs and symptomsS/SE symptoms/side effectsSA node sinus-atrial nodeSaO2 oxygen saturation in arterial bloodSAQ short arc quadsSASH Saline Antibiotics Saline HeparinSBA stand by assistanceSE side effects

Page 17 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 18

SEC secondarysed rate sedimentation rateSGOT serum glutamic oxaloacetic transaminaseSGPT serum glutamic pyruvic transaminaseSLB short leg braceSLP Speech Language PathologistSLR straight leg raiseSMA12 sequential multiple analysis of 12 chemistry constituentsSMAC sequential multiple analyzer with compoundSN skilled nursingSNF Skilled Nursing FacilitySNV Skilled Nursing VisitSO4 sulfateSOB shortness of breathSOC start of care dateSP Speech PathologistSPA SpanishSPC single point canespec. specimenspon., spont spontaneousSPOU spouseSPT stand/pivot/transferSR side railsSRMC Sampson Regional Medical CenterSS Social SecuritySSE soap suds enemaST, SP Tx speech therapySTAT at oncestim stimulationSUBQ subcutaneousSup Supervision, supervisorySV supervisory visitSVC superior vena cavaSW Social WorkerSWAL swallowing

Page 18 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 19

Sx, sympt symptomsSyl. syllablesT&A tonsillectomy and adenoidectomyT, temp temperatureT.O. telephone ordert/f transferT/F SPT transfer (stand, pivot, transfer)tab tabletTB tuberculosisTBI traumatic brain injuryTbsp tablespoonTC&DB or TCDB turn, cough and deep breatheTD transdermalTDWB touch down weight bearingTech. techniqueTher act Therapeutic activitiesTher ex therapeutic exercisesTHR total hip replacementTIA transient ischemic attacktid, t.i.d. three times a dayTKR total knee replacementtol. toleratesTPR temperature, pulse and respirationstrach tracheostomyTSA total shoulder arthroplastyTSH thyroid stimulating hormoneTSM Dressing Transparent Semipermeable Membranetsp teaspoonTT transfer trainingTTB tub transfer benchTTWB toe touch weight bearingTUR transurethral resectionTURP transurethral resection prostate; Transurethal ProstectomyTV tidal volumeTx treatment

Page 19 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 20

UA urinalysisUB upper bodyUE upper extremitiesUGI upper gastrointestinalUKO unknown originumb umbilicus, umbilicalUNC University of North Carolina Chapel HillUR Utilization ReviewURI upper respiratory infectionUTI urinary tract infectionVA Veteran's Administration/vaginalVAD vascular access devicevag vaginalVC/S AD verbal cues without assistive deviceVCS verbal cuesVD venereal diseaseVent ventilatorvia by way ofvit vitaminVO verbal ordervol volumeVP venipunctureVS vital signsw/c wheelchairw/d warm and dryw/o withoutw/p, WP whirlpoolWBAT weight bearing as toleratedWBC white blood cells, white blood countWC wound careWFL within functional limitsWilMed Wilson Memorial Hospitalwk weekWMC Wake Medical CenterWMH Wayne Memorial Hospital

Page 20 of 21

14.10 ACCEPTABLE ABBREVIATIONS AND ACRONYMS FOR CHARTINGPage 21

WND woundWNL within normal limitswt. weightx timesyr year

* symbols increase increased decreased@ at~ approximate2 secondary to° degree- minus, negative+ plus, positive= equal to Δ change> greater than< less than♂ male♀ female# number, pounds÷ divided by% percent& andc withp afters withoutā before

Page 21 of 21