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