Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
APPROVED AND UNAPPROVED ABBREVIATIONS AND SYMBOLS FOR MEDICAL RECORDS
PURPOSE:
To establish a database of acceptable ocular and medical abbreviations for patient medical records. To list the abbreviations that are NOT approved for use in patient medical records.
POLICY:
Following is the list of abbreviations that are NOT approved – never to be used – for use in patient medical records, all orders, and all medication-related documentation that is either hand-written (including free-text computer entry) or pre-printed:
DO NOT USE POTENTIAL PROBLEM USE INSTEAD U (unit) Mistaken for “0” (zero), the Write “unit” number “4”, or “cc” IU (international unit) Mistaken for “IV” (intravenous) Write “international unit” or the number 10 (ten). Q.D., QD, q.d., qd (daily) Mistaken for each other Write “daily” Q.O.D., QOD, q.o.d., qod Period after the Q mistaken for Write (“every other day”) (every other day) “I” and the “O” mistaken for “I” Trailing zero (X.0 mg) ** Decimal point is missed. Write X mg Lack of leading zero (.X mg) Decimal point is missed. Write 0.X mg MS Can mean morphine sulfate or Write “morphine sulfate” or magnesium sulfate “magnesium sulfate” MSO4 and MgSO4 Confused for one another Write “morphine sulfate” or “magnesium sulfate”
** Exception: A trailing zero may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
Page 1 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
Following is the list of abbreviations that are approved for use in IEI patient medical records. Note that abbreviations of conditions should not be used when documenting diagnoses or complications in the assessment portion of the medical record or the master problem list.
It is recommended that practitioners and student clinicians minimize the use of abbreviations and, when possible, write out the full terminology or name in order to be as clear as possible for the next provider of care. If there is any doubt about the intention or meaning of an abbreviation, please seek explanation prior to treating the patient.
ARC anomalous retinal correspondence @ at ARMD age-related macular degeneration A assessment or alternating (AET, A/S antisuppression Alternating Esotropia, etc.) AT artificial tears abn abnormal AS anterior synechiae ac before meals ASA aspirin (acetylsalicylic acid) AC anterior chamber or anomalous ASAP as soon as possible correspondence ASC anteior subcapsular cataract ACC accommodation asph aspheric ACE angiotensin-converting enzyme astig astigmatism ACG angle-closure glaucoma ATR against-the-rule (astigmatism) ACIOL anterior chamber intraocular lens A/V arteriolar/venous (ratio, nicking) ACT alternating cover test B. string Brock string Add adduction or bifocal power BAK benzalkonium chloride adv advanced BB binocular balance AE accommodative excess BC base curve AI after image or accommodative BCP birth control pill insufficieny BCR base curve radius AIDS acquired immunodeficiency syndrome BDR background diabetic retinopathy AION anterior ischemic optic neuropathy BF bifocal AK astigmatic keratectomy BI base in Alph Alphagan bid twice a day ALT argon laser trabeculoplasty bif bifocal AMA against medical advice bilat bilateral Ambl amblyopia BIM base-in/minus AMD age-related macular degeneration BINO bilateral internuclear ophthalmoplegia AMPPE acute multifocal placoid pigment BIO binocular indirect ophthalmoscope epitheliopathy (ophthalmoscopy) ANA antinuclear antibody BITA bilevel Angle A angle of anomaly bleph blepharitis Angle D objective angle of strabismus BO base out Angle S subjective angle BOP base-out/plus ant anterior BP blood pressure AODM adult-onset diabetes mellitus BRAO Branch retinal artery occlusion APD afferent pupillary defect BRVO branch retinal vein occlusion AP Rule Aperture Rule BTL behind the lens approx approximately BU base up
Page 2 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
BUN blood urea nitrogen CP cerebral palsy BUT break-up time CPM continue prescribed medication BV binocular vision CPR cardiopulmonary resuscitation BVA best visual acuity CR chorioretinal BW broken wheel CRAO central retinal artery occlusion bx biopsy CRVO central retinal vein c with CS cortical spoking C cornea or cycloplegic C&S culture and sensitivity CA carcinoma CSF cerebrospinal fluid CABG coronary artery bypass graft CSM central, steady, maintained CACG chronic angle closure glaucoma CSME clinically significant macular edema CAD coronary artery disease CSC central serous chorioretinopathy CAI carbonic anhydrase inhibitor CT cover test or center thickness cap(s) capsule(s) cyclo cycloplegic cat cataract CT scan computed tomographic scan CAT computed axial tomography CV color vision CB ciliary body CVA cardiovascular accident CBC complete blood count or CVD cardiovascular disease Clear/blur/clear CWS cotton-wool spot cc with correction Cx culture CC chief complaint cyl cylinder CCC central corneal clouding D 250 Diamox 250-mg tablets CCCV clear, comfortable, central vision D diopter or diameter or disc CCTV closed-circuit television D/C discontinue c/d or C/D cup-to-disc ratio D&Q deep and quiet CE convergence excess or cataract DD disc diameter extraction DDx differential diagnosis CF count fingers or confrontation field DE divergence excess C&F cells and flare Dec decenter CHA compound hyperopic astigmatism DFE dilated fundus examination CHF congestive heart failure DFV Designs for Vision CHRPE congenital hypertrophy of the retinal DI divergence insufficiency pigment epithelium D&I dilation and irrigation CI convergence insufficiency dia or diam diameter CL contact lens or clear disp dispense cm centimeter dist distance CMA compound myopic astigmatism Dk/L oxygen transmissibility of a contat lens CME cystoid macular edema DM diabetes mellitus CMV cytomegalovirus DME diabetic macular edema CN cranial nerve DPA’s diagnostic pharmaceutical agents CNS central nervous system DR diabetic retinopathy CNV choroidal neovascular membrane DVA distance visual acuity c/o complaining of DW daily wear COAG chronic open-angle glaucoma Dx diagnosis COIL Combined Optical Industries Limited EBMD epithelial basement membrane dystrophy cone keratoconus ECCE extracapsular cataract extraction cong congenital ED electrodiagnostic (testing) or educated conj conjunctiva EF eccentric fixation COPD chronic obstructive pulmonary disease EKC epidemic keratoconjunctivitis
Page 3 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
EKG or ECG electrocardiogram FTFC full-to-finger counting ELISA enzyme-linked immunosorbetn assay FTW full-time wear endo endothelium f/u follow-up ENG electronystagmogram GCA giant cell arteritis ENT ear, nose, throat GEE general eye exam enz enzyme GF grandfather EOG electro-oculography GI gastrointestinal EOM extraocular muscles GLC glaucoma EP esophoria at far GM grandmother EP’ esophoria at near GO, GI, GII grades of anterior chamber angle: GO= epith epithelium GIII, GIV closed; GIV = wide open ER emergency room or emergency gonio gonioscopic examination ERG electroretinography GOS general opthalmology service ERM epiretinal membrane GPC giant papillary conjunctivitis Eschen Eschenbach gt drop (plural, gtt) eso esophoria GTT glucose tolerance test ESR erythrocyte sedimentation rate (sed rate) GVF Goldmann visual field ET constant esotropia at far or edge h or hr hour thickness HA headache ET’ constant esotropia at near hab habitual IET intermittent esotropia at far HAG Home Amsler Grid IET’ intermittent esotropia at near Hb hemoglobin ETOH ethyl alcohol HBAIT Hering-Bielschowsky after image test EV eccentric viewing HBP high blood pressure eval evaluation HC Hart chart EW extended wear HCL hard contact lens EXT external ocular examination, including HCTZ hydrocholorothiazide adnexa hem or heme hemorrhage exoph exophthalmos Hg mercury exo exophoria HH handheld F fluorescein or father HHM hand-held magnifier FA or FANG fluorescein angiography HHTS hand-held telescope FAZ foveal avascular zone HIV human immunodeficiency virus FB foreign body HLA histocompatibility locus antigen or FBS fasting blood sugar Human leukocyte antigen FC finger count h/o history of FD fixation disparity horiz horizontal FERG focal electrogram H 2O water FFSM fixed focus stand magnifier HM hand motion or hand magnifier FH or FHx family history H&P history and physical FLP forced preferential looking acuity HPA high plus add FMHx family medical history hs at bedtime FML fluorometholone HSK herpes simplex keratitis FOHx family ocular history HSV herpes simplex virus FP Flouroperm HT hypertropia at far or height FR foveal reflex HT’ hypertropia at near FROM full range of motion HTN hypertension FTA-ABS fluorescent treponemal antibody HVF Humphrey visual field absorption test Hx history
Page 4 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
HZO herpes zoster ophthalmicus LSO left superior oblique I intermittent (IAET, intermittent LSR left superior rectus Alternating esotropia, etc.) or inferior LTP laser trabeculoplasty ICA internal carotid artery LVA low vision aids ICCE intracapsular cataract extraction Lymph lymphocytes or lymphatic ICE iridocorneal endothelial syndrome m meter or month ICR intermediate curve radius MA mixed astigmatism ICU intensive care unit M manifest refraction or macula or mother ICW intermediate curve width mac macula I&D incision and drainage max maximum IDDM insulin-dependent diabetes mellitus meds medications IEI Illinois Eye Institute MEM monocular estimate method Ig immunoglobulin MEWDS multiple evanescent white dot syndrome IK interstitial keratitis MFS monofixation syndrome IM intramuscular MG Marcus Gunn Imp impression mg milligram Inf inferior MGD meibomian gland dysfunction Inj injection MGF maternal grandfather IN inferonasal MGM maternal grandmother INO internuclear ophthalmoplegia MHx medical history int intermittent MI myocardial infarction IOL intraocular lens min minute or minimum ION ischemic optic neuropathy ml milliliter IOP intraocular pressure mm millimeter IR infrared MM malignant melanoma IRMA intraretinal microvascular abnormality mm Hg millimeters of mercury IT inferotemporal M&N Mydriacyl (tropicamide) and IV intravenous Neo-synephrine (phenylephrine) JRA juvenile rheumatoid arthritis mot motility K potassium or keratometry mp multipack KCS keratoconjunctivitis sicca MRI magnetic resonance imaging Kg kilogram MS multiple sclerosis KP keratic precipitate MVA motor vehicle accident L left or lens mvt movement lab laboratory Myd Mydriacyl lac lacrimal N nasal LASIK laser in situ keratomileusis N/A not applicable or not available LD learning disabled NaCl sodium chloride LKP lamellar keratoplasty NaFl sodium fluorescein LIO left inferior oblique NAG narrow-angle glaucoma LIR left inferior rectus NAP no apparent pathology LL lids and lashes or lower lid NC normal correspondence LLR left lateral rectus NCT noncontact tonometer (tonometry) LMR left medial rectus neg negative LOZ lenticular optical zone neo neovascularization or neosynephrine LP light perception, light projection, NFL nerve fiber layer lumbar puncture or lateral phoria NFLD nerve fiber layer defect LPI laser peripheral iridotomy NI no improvement LS lid scrubs or life saver card NIDDM non-insulin-dependent diabetes mellitus
Page 5 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
NKA no known allergies P4, P2, etc. pilocarpine 4%, 2%, etc., drops NKMA no known medical allergies PB prism bar nl or nml normal pc after meals NLP no light perception PC posterior capsule or polycarbonate NM no movement PCF pharyngoconjunctival fever NPC near point of convergence PCIOL posterior chamber intraocular lens NPDR nonproliferative diabetic retinopathy PCN penicillin NR no refill PCP primary care provider NRA negative relative accommodation PCR peripheral curve radius NRC normal retinal correspondence PCW peripheral curve width NRR neural retinal rim PD pupillary distance NS nuclear sclerosis PDR proliferaive diabetic retinopathy NSAID nonsteroidal anti-inflammatory drug PDS pigment dispersion syndrome NTG normotensive glaucoma PE Phenylephrine NV near vision or neovascularization PEE punctate epithelial erosions NVA near visual acuity PEK punctate epithelial keratitis NVD neovascularization of the disc PERG pattern electrogram NVE neovascularization of the retina PERRLA pupils equal, round, reactive to light elsewhere and accommodation NVG neovascular glaucoma PF Pred Forte NVI neovascularization of the iris Pg pregnant O objective PGF paternal grandfather O2 oxygen PGM paternal grandmother OAD overall diameter ph pinhole OAG open-angle glaucoma phako phakoemulsification OD right eye Phenyl Phenylephrine ODM ophthalmodynamometry PHNI or NIph pinhole no improvement OFHx ocular family history PHPV persistent hyperplastic primary vitreous OGTT oral glucose tolerance test PI present illness, peripheral iridotomy, or OHTN ocular hypertension peripheral iridectomy OHx ocular history PKP pentrating keratoplasty OKN optokinetic nystagmus PMMA polymethylmethacrylate OM oculomotor PMN polymorphonuclear neutrophil ON optic nerve P-M Pen Perceptual-Motor Pen ONH optic nerve head po per os, by mouth OR operating room POAG primary open-angle glaucoma Ortho-K ortho-keratolaogy POHx positive ocular history OS left eye POHS presumed ocular histoplasmosis OTC over the counter Syndrome OU both eyes PMHx positive medical history OZ optical zone post posterior P pupil or periphery or pursuits or plan PPD purified protein derivative or posterior p post, after polymorphous dystrophy PAL progressive addition lens PPDR preproliferative diabetic retinopathy PAM potential acuity meter PPU pencil push-up PAN preauricular node PPLOV painless progressive loss of vision PAS peripheral anterior synechia PPV pars plana vitrectomy pat or pt patient prep preparation path pathology PRK photorefractive keratectomy
Page 6 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
PRA positive relative accommodation Rx prescription prn take as needed s without PRP panretinal photocoagulation S subjective or superior or saccades PS posterior synechia sac saccades PSC posterior subcapsular cataract sc without correction Pt patient SC secondary curve purs pursuits SCL soft contact lens p-u amp push-up amplitude SCr secondary curve radius p-a amp push-away amplitude SCw secondary curve width PVA polyvinyl alcohol SD scleral depression PVD poserior vitreous detachment seg segment Px prognosis SE’s side effects q every Sed rate erythrocyte sedimentation rate qd every day SEI subepithelial infiltrate q2h, etc. every 2 hours, etc. sig write on label qid four times a day SILO small in, large out q/o question of SL Schwalbe’s line or serum lysozyme qod every other day SLE systemic lupus erythematosus or slit R right or retinoscopy lamp examination RA rheumatoid arthritis SLE slit lamp examination RB rose bengal or retinal break SLK superior limbic keratoconjunctivitis RBC red blood cell or retinal break SH simple hyperopia RBON retrobulbar optic neuritis SM stand magnifier or simple myopia RCE recurrent corneal erosion SN superonasal or signs RD retinal detachment SOB shortness of breath RDV reciprocal of distance vision sol solution re regarding SOMS Single Oblique Mirror Stereoscope rec recommend S/P status post Ret retinoscopy SPK superficial punctate keratitis RF rheumatoid factor SpTS spectacle telescope R-G red-green SR subjective refraction RGP rigid gas permeable SRF subretinal fluid RH retinal hole SRNVM subretinal neovascularization membrane RI rubeosis iridis SRx spectacle prescription RIO right inferior oblique SS scleral spur or sickle cell disease RIR right inferior rectus S/S signs and symptoms RK radial keratotomy ST superotemporal RLR right lateral rectus Std standard RMR right medial rectus strab strabismus RNV reciprocal of near vision subj subjective R/O rule out sup superior ROP retinopathy of prematurity supp suppression RORx reading only spectacles susp suspension RP retinitis pigmentosa SVP spontaneous venous pulsations RPE retinal pigment epithelium Sx symptom RSO right superior oblique synech synechia RSR right superior rectus T temporal RT return T ¼, T ½ Timoptic drops ¼%, ½% RTC return to clinic TA temporal arteritis
Page 7 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
Tab(s) tablet(s) Vsc vision without correction TA applanation tonometry VZV varicella-zoster virus TB tuberculosis VT vision therapy TBUT tear break-up time w week TDx tentative diagnosis W-4-D Worth-four-dot TED thyroid eye disease WBC white blood cell temp temporal WC warm compresses TF trial frame WC/LS warm compresses and lid scrubs TIA transient ischemic attack WD working distance tid three times a day WNL within normal limits TM trabecular meshwork WSF Wayne Saccadic Fixator TMB transient monocular blindness wt weight or wearing time TMS telemicroscope Xal Xalatan Tnct noncontact (air puff) tonometry XP exophoria at far TOV transient obscuration of vision XP’ exophoria at near TPA’s theraputic pharmaceutical agents XT constant exotropia at far trab trabeculectomy XT’ constant exotropia at near Tran Tranaglyph IXT intermittent exotropia at far trif trifocal IXT’ intermittent exotropia at near Trop Tropicamide y year Trus Trusopt YAG yttrium aluminum garnet TS telescope YLI YAG laser iridotomy TSH thyroid-stimulating hormone y/o years old Tx treatment or traction YPC YAG laser posterior capsulotomy UA urinalysis 60W/x/OLS 60 watt bulb at x inches over left UCT unilateral cover test shoulder UL upper lid ung ointment URI upper respiratory infection US unsteady ut dict as directed UTI urinary tract infection UTT unable to test UV ultraviolet V vitreous or vessels VA visual acuity Vcc vision with correction Vccl vision with contact lens VD veneral disease VDRL Veneral Disease Research Laboratory Vecto Vectogram VER visual evoked response vert vertical VF visual fields vit vitreous VKC vernal keratoconjunctivitis VKH Vogt-Koyanagi-Harada syndrome VP vertical phoria vs versus
Page 8 of 9 Facility: Illinois College of Optometry and Illinois Eye Institute Policy: Approved And Unapproved Abbreviations and Symbols for Medical Records Manual: Information Management Effective: January 1999 Revised: March 2009 (M.Butz) Review Dates: March 2003 (V.Conrad) March 2008 (M.Butz)
Symbols
κ orthophoric (lateral) at far κ’ orthophoric (lateral) at near √ orthophoric (vertical) at far √’ orthophoric (vertical) at near ↵ orthophoric (lateral and vertical) at far ↵’ orthophoric (lateral and vertical) at near & female % male - minus + plus or positive or and = equal to ≠ not equal to ≈ approximately equal 1o primary 2o secondary ∅ none or no >(≥) greater than (greater than or equal to) <(≤) less than (less than or equal to) ∆ change or prism diopter ∴ therefore 1 one (drops, tablets, etc. Β two (drops, tablets, etc.) Τ three (drops, tablets, etc.) ↑ increased ↓ decreased # number or pound
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