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Approved and Unapproved Abbreviations and Symbols For 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
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