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Transcript
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
APPROVED ABBREVIATION LIST FOR
USE IN MEDICAL RECORDS
POLICY
©
DOCUMENT SUMMARY/KEY POINTS
•
All medical records must be legible and easily understood by all persons who access
them; including consumers and external agencies.
•
Only approved abbreviations and symbols may be used in patient’s medical record.
(draft NSW Health Policy Directive Health Care Records – Management & Documentation)
•
Medical diagnosis must be written in full.
•
If however, a medical diagnosis appears on the Approved Abbreviation list, it must be
written in full in the first instance, followed by the abbreviation in brackets and then the
abbreviation may be used thereafter. For example, urinary tract infection (UTI).
This policy:
o
Contains the authorised list of abbreviations to be used at The Children’s Hospital at
Westmead (CHW) including codes required for episode funding.
o
Applies to all medical records whether hard copy, electronic, a hybrid of both or in
other forms.
o
Replaces any local abbreviation lists held at discipline or department level.
•
Approved Abbreviations for use when prescribing medications are also contained within
the CHW Medication Management And Handling Practice Guideline
http://intranet.kids/o/documents/policies/guidelines/2006-8232.pdf
•
The use of abbreviations is not permitted when documenting:
•
o
On Consent Forms
o
Surgical Operations and Diagnostic Procedures requiring general anaesthetic
o
Name of drugs
Abbreviations used on Forms that have been endorsed by the Forms Committee are
only approved to be used within that Form itself
Note: This is a list of Approved Abbreviations to be used within CHW. Any
abbreviation outside of this list is NOT approved for use in clinical documentation at
CHW.
Approved by:
Date Effective:
Team Leader:
CHW Policy and Procedure Committee
1st January 2012
CRU Project Officer
CHW Improvement & Safety Committee
Review Period: 3 years
Area/Dept: Clinical Governance Unit
Date of Publishing: 23 December 2011 2:37 PM
Date of Printing: 23 December 2011
K:\CHW P&P\ePolicy\Dec 11\Approved Abreviation List for use in MR.docx
Page 1 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
CHANGE SUMMARY
•
N/A – new policy.
READ ACKNOWLEDGEMENT
•
All staff that document directly into patients health care records are required to read
and acknowledge the document
•
All staff responsible for the maintenance, storage and review of health care records
are required to read and acknowledge the document
Approved by:
Date Effective:
Team Leader:
CHW Policy and Procedure Committee
1st January 2012
CRU Project Officer
CHW Improvement & Safety Committee
Review Period: 3 years
Area/Dept: Clinical Governance Unit
Date of Publishing: 23 December 2011 2:37 PM
Date of Printing: 23 December 2011
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Page 2 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
TABLE OF CONTENTS
1
Introduction/background ............................................................................................ 4
1.1
Definitions ...................................................................... Error! Bookmark not defined.
2
Scope ............................................................................................................................4
2.1
Inclusions.......................................................................................................................4
2.2
Exclusions .....................................................................................................................5
Abbreviations used on Forms: ............................................................................................. 5
eMR Pathology Orders – Abbreviations: ............................................................................. 5
Abbreviations for prescribing and ordering medications ...................................................... 5
3
When abbreviations cannot be used ......................................................................... 5
3.1
Abbreviations must not be used in the following situations: .......................................... 5
3.2
Use of Symbols and Chemical Names .......................................................................... 5
4
Medical diagnosis........................................................................................................ 5
5
Approved Abbreviation List ....................................................................................... 6
5.1
Staff Designations ......................................................................................................... 6
5.2
General Abbreviations (alphabetical list) ....................................................................... 6
A-B-C ................................................................................... Error! Bookmark not defined.
D-E-F ...................................................................................................................................8
G-H-I ....................................................................................................................................9
J-K-L ..................................................................................................................................10
M-N-O ................................................................................................................................10
P-Q-R-S .............................................................................................................................11
T-U-V .................................................................................................................................12
W–X–Y–Z ..........................................................................................................................13
Date of Publishing: 23 December 2011 2:37 PM
Date of Printing: 23 December 2011
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Page 3 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
1
Introduction/background
All medical records must be legible and easily understood by all persons who access them;
including consumers and external agencies.
Use of approved abbreviations will improve documentation, communication and patient
outcomes by reducing misinterpretations and provide medico – legal protection for staff.
Health care record
The main purpose of a health care record is to provide a means of communication to
facilitate the safe care and treatment of a patient/client.
A health care record is the primary repository of information including medical and
therapeutic treatment and intervention for the health and wellbeing of the patient/client during
an episode of care and informs care in future episodes. The health care record is a
documented account of a patient/client’s history of illness; health care plan/s; health
investigations and evaluations; diagnosis; care; treatment; progress and health outcomes for
each health service intervention or interaction.
The health care record may also be used for communication with external health care
providers, and statutory and regulatory bodies, in addition to facilitating patient safety
improvements; investigation of complaints; planning; audit activities; research (subject to
ethics committee approval, as required); education; financial reimbursement and public
health. The record may become an important piece of evidence in protecting the legal
interests of the patient/client, health care personnel, other personnel or Public Health
Organisations (PHO).
The health care record may be paper, electronic or a combination of both. Where a health
care record exists in both paper and electronic form this is referred to as a hybrid record.
Where PHOs maintain a hybrid record, health care personnel must have access to
information that is included in each part of the record.
2
Scope
This policy:
•
Applies to health care records that are the property of, and maintained by, PHO,
including health care records of private patients seen in the PHO.
•
Does not apply to records that may be maintained by patient/clients and records that
may be maintained by clinicians in respect of private patients seen in private rooms.
•
Replaces any local abbreviation list held at discipline or department level used for
medical record documentation.
2.1
Inclusions
•
The approved abbreviation list applies to documentation in all health care records at
the CHW whether they be in hard copy, electronic, in both (hybrid) or in any other forms
(e.g. video/CD).
•
Abbreviations required for Episodic Based Funding Coding.
Date of Publishing: 23 December 2011 2:37 PM
Date of Printing: 23 December 2011
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Page 4 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
2.2
Exclusions
Abbreviations used on Forms:
•
Some CHW Forms contain abbreviations, legends or explanations for these
abbreviations may be included on the actual Form.
•
In the circumstance that there are abbreviations on a Form, and this Form has a
Medical Records barcode, then the abbreviation may continue to be used on the Form
itself, however, it is not acceptable to be used within other clinical notes.
eMR Pathology Orders – Abbreviations:
•
NSW Health, in the eMR Pathology Orders Design Recommendations, has included
some abbreviations in the pathology orderables list. These abbreviations were included
in the CHW Powerchart pathology orders build however may not be used outside of
Powerchart in other clinical notes.
Abbreviations for prescribing and ordering medications
•
Approved abbreviations for use when prescribing medications are also contained within
the CHW Medication Management And Handling Practice Guideline
http://intranet.kids/o/documents/policies/guidelines/2006-8232.pdf#page=14
3
3.1
•
•
•
3.2
When abbreviations cannot be used
Abbreviations must not be used at all in the following
situations:
On Consent forms
In documentation of Surgical Operations and Diagnostic Procedures requiring general
anaesthetic
When documenting the name of a drug
Use of Symbols and Chemical Names
The use of symbols and chemical names in hand written or electronic clinical notes is not
permitted as they can potentially be misinterpreted as per the NSW Therapeutic Advisory
Group. http://www.ciap.health.nsw.gov.au/nswtag/publications/guidelines/TERMINOLOGY1206.pdf
Symbols and Chemical Names need to be written out in full.
4
•
•
Medical Diagnosis
Medical diagnosis must be written in full.
If however, a medical diagnosis appears on the Approved Abbreviation list, it must be
written in full in the first instance followed by the abbreviation in brackets and then the
abbreviation may be used thereafter. For example, urinary tract infection (UTI).
Date of Publishing: 23 December 2011 2:37 PM
Date of Printing: 23 December 2011
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Page 5 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
5
Approved Abbreviation List
5.1
Staff Designations
Abbreviation
Description (meaning)
AHNM
AMO
CLT
CNC
CNE
CNS
DON
Dr
EEN
EN
JMO
NE
NP
NUM
Occ Ther
Physio
Reg
RN
RM
RMO
SMO
SW
SP
VMO
After Hours Nurse Manager
Admitting Medical Officer
Child Life Therapy
Clinical Nurse Consultant
Clinical Nurse Educator
Clinical Nurse Specialist
Director of Nursing Services
Doctor
Endorsed Enrolled Nurse
Enrolled Nurse
Junior Medical Officer
Nurse Educator
Nurse Practitioner
Nurse Unit Manager
Occupational Therapist
Physiotherapist
Registrar (Medical Officer)
Registered Nurse
Registered Midwife
Resident Medical Officer
Senior Medical Officer
Social Worker
Speech Pathologist
Visiting Medical Officer
5.2
General Abbreviations (alphabetical list)
ABBREVIATION
DESCRIPTION (MEANING)
COMMENT
A-B-C
AAA
ABG
ACT
ADHD
ADL
ADC
AEDs
AF
A.Flutter
AFO
aGVHD
AIDS
AICD
A/O
ARF
Abdominal aortic aneurysm
Arterial blood gas
Acceptance and commitment therapy
Attention deficient hyperactivity disorder
Activities of daily living
Adenocarcinoma
Antiepileptic drugs
Atrial fibrillation
Atrial Flutter
Ankle foot Orthosis
Acute graft versus host disease
Acquired immune deficiency syndrome
Automatic implantation cardioverter defibrillator
Application of
Acute renal failure
For patient with monitor
For patient with monitor
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Date of Printing: 23 December 2011
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Page 6 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
AML
AND
Appt.
ARDS
ASD
ATN
Ausc.
AV
AVPU
AVSD
Ax
bd
BBB
BCC
BC
BCPC
BCPS
BCG
BIBA
BIH
BiPAP
BMA
BMAT
BMI
BMIz
BNO
BO
BP
BSA
BSL
BW
Bx
C (1-7)
C&S
Cals
Cap
CAPAC
CAPD
CAVH
CAVHD
CBT
CCF
CCU
CERS
CF
CFRD
CGH array
CHI
CNS
CLL
c/o
Acute myeloid leukaemia
Allow Natural Death
Appointment
Acute respiratory distress syndrome
Atrial septal defect
Acute tubular necrosis
Auscultation
Aortic Valve or Arteriovenous or Atrioventricular
Alert, responds to voice, responds to pain,
unresponsive
Atrioventricular septal defect
Assessment
Twice daily – Twice a Day
Bundle branch block
Basal cell carcinoma
Blood cultures
Bidirectional cavopulmonary connection
Bidirectional cavopulmonary shunt
Baccili Calmette-Guerin Injection (TB Vaccine)
Brought in by Ambulance
Benign Intracranial Hypertension
Bi-level positive airway pressure
Bone Marrow Aspirate
Bone Marrow Aspiration and trephine
Body Mass Index
Body Mass index for age
Bowels Not Open
Bowels Open
Blood Pressure
Body Surface Area
Blood sugar level
Birth weight
Biopsy
Cervical ( 1 – 7 ) e.g. C5 quadriplegic
Culture and sensitivity
Calories
Capsule
Community Acute Post-Acute Care
Continuous ambulatory peritoneal dialysis
Continuous Arteriovenous hemofiltration
Continuous Arteriovenous haemodialysis
Cognitive behaviour therapy
Congestive cardiac failure
Clean Catch Urine
Clinical Emergency Response System
Cystic Fibrosis
Cystic Fibrosis Related diabetes
Comparative Genomic Hybridization array
Closed head injury
Central nervous system
Chronic lymphocytic leukaemia
Chronic lymphoid leukaemia
Complained of
physio
Paediatric Consciousness Score
Only use as Cervical
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Page 7 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
COP
CML
CN (1-12)
CP
CPAP
CPM
CPP
CPR
CRF
CREST
CSA
CSF
CSU
CT(Scan)
CVAD
CVC
CVVH
CVVHDF
CVP
CXR
D-E-F
DB & C
DBD
DCD
D/C
Dept.
DOB
DoCS
D&V
DI
DIC
DISIDA
DNA
DSA
DTPA
Dx
DXRT
DV
D/W
ECG
Echo
ECMO
ECT
EEG
EER
E/o
EFR
EHM
EMG
ENT
EOM
Change of Plaster
Chronic myelocytic leukaemia
Chronic myeloid leukaemia
Cranial Nerve
Cerebral Palsy
Continuous positive airways pressure
Continuous passive movement
Cerebral Perfusion Pressure
Cardiopulmonary resuscitation
Chronic renal failure
Raynaud’s phenomenon
Child Sexual Assault
Cerebrospinal fluid
Catheter specimen of urine
Computerised axial tomography (scan)
Central Venous Access Device
Central Venous Catheter
Continuous veno-veno haemofiltration
Continuous veno-veno haemodialysis
Central Venous Pressure
Chest X-Ray
Description/meaning
Deep Breathing and coughing
Donation after brain death
Donation after cardiac death
Discharge
Department
Date of Birth
Department of Community Services
Diarrhoea and vomiting
Diabetes Insipidus
Disseminated Intravascular Coagulopathy
Diisopropyl iminodiacetic acid scan
Deoxyribonucleic Acid
Digital Subtraction Angiography
Diethylene-triamine-penta-acetic acid Scan
Diagnosis
Deep X-Ray Therapy
Domestic Violence
Discussed with
Electrocardiogram
Echocardiogram
Extracorporeal Membrane Oxygenation
Electroconvulsive therapy
Electro-encephalogram
Estimated Energy Requirement
Excision of ……….
Estimate Fluid Replacement
Expressed Human Milk
Electromyogram
Ear nose and throat
External Ocular Muscles
Comment
also examination of
Date of Publishing: 23 December 2011 2:37 PM
Date of Printing: 23 December 2011
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Page 8 of 13
This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
EPR
EPS
ERCP
ESR
ETT
ESRF
EUA
EVD
FBC
F i O2
FNAB
FEV1
FESS
FIVD
FROM
FSCM
FTT
F/U
FVC
FWB
G-H-I
G (number)
g
GA
GCS
GFMCS
GFR
G&H
GIT
GM Stain
GP
GVHD
Hb
HC
HCCC
HH
HMD
hrly
HR
HSDNM
Ht.
ICC
ICP
IDC
IG
IIMS
IM
Inhaler
IMI
Inj
I/O
IOL
IV
IPPV
IVAD
Estimated Protein replacement
Electrophysiological studies
Endoscopic retrograde cholangio-pancreatogram
Erythrocyte sedimentation rate
Endotracheal tube
End stage renal failure
Examination under anaesthetic
External Ventricular Drain
Full blood count
Fraction inspired oxygen
Fine needle aspiration biopsy
Forced expiratory volume over one second
Functional endoscopic sinus surgery
Fixed Interval Variable Dose
Full Range of Movement
Full strength cow’s milk
Failure to thrive
Follow up
Forced vital capacity
Full weight bearing
Description/meaning
Gravida
Gram(s)
General anaesthetic
Glasgow Coma Scale
Gross Motor Function classification system
Glomerular Filtration Rate
Blood Group and Hold Serum
Gastrointestinal tract
Gram Stain
General Practitioner
Graft versus host disease
Haemoglobin
Head Circumference
Health Care Complaints Commission
Hiatus hernia
Hyaline membrane disease
Hourly (write number of hours + hrly or hourly)
Heart Rate
Heart sounds dual and no murmur
Height
Intercostal catheter
Intracranial pressure
Indwelling catheter
Intragastric
Incident Information Management System
Intramuscular
Metered Dose Inhaler, MDI
Intramuscular injection
Injection
Insertion of
Intraocular lens
Intravenous
Intermittent positive-pressure ventilation
Implantable venous access device
Comment
Neurology use
e.g. 1 hrly or 4 hrly
Date of Publishing: 23 December 2011 2:37 PM
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
IVI
IVC
IVP
Intravenous injection
Inferior vena cava
Intravenous pyelogram
J-K-L
Description/meaning
JVP
kCal
kJ
KUB
k-wire
L
L (1 to 5)
Jugular venous pressure
Kilocalories
Kilojoules
Kidney urinary bladder
Kirshiner wire
Litre(s)
Lumbar e.g. L2 fracture
LA
LBO
LBW
LCT
LFT’s
LIF
LIH
LLL
LLQ
L/N
LOC
Local anaesthetic
Laryngo broncho-oesphagoscopy
Low birth Weight
Long Chain Triglycerides
Liver Function tests
Left iliac fossa
Left inguinal hernia
Left lower lobe
Left Lower Quadrant
Lymph node
Loss of consciousness
LP
LRD
LRTI
LSCS
LUQ
Lumbar puncture
Living related donor
Left respiratory tract infection
Lower Segment Caesarean Section
Left upper quadrant
M-N-O
MAP
MAG3
mane
MC&S
MCT
MDI
Mec.
MIBG
microg
mg
mL
MM
mmol
MMSE
MODY
mOsm
MRI
MRSA
MSU
MVA
NAI
NAD
NBM
Description/meaning
Also intravenous cannula
Comment
Could be mistaken for the volume
litres
Not to be used for level of
consciousness
Comment
Mean Arterial Pressure
As per DTPA scan
Morning
Microscopy, culture & sensitivities
Medium Chain Triglycerides
Metered Dose Inhaler
Meconium
Meta-iodobenzylguanidine
Microgram
Milligram(s)
Millilitre(s)
Multiple myeloma
Millimole
Mini Mental State Exam
Maturity onset diabetes mellitus in the young
Milliosmoles
Magnetic Resonance Imaging
Multiple resistant staphylococcus aureus
Methicillin resistant staphylococcus aureus
Mid-stream specimen of urine
Motor vehicle accident
Non Accidental Injury
No abnormality detected, e.g. ward test - N.A.D.
Nil by mouth
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
NCA
NEB
NETS
NG
NHL
NIDDM
NIM
NIV
Nocte
NOF
NPA
NR
No.
NWB
O2 Sat.
Obs.
O/A
O/E
ODD
OG
Oint.
ORIF
OR
OT
P-Q-R-S
P (number)
PAC
PAH
PBSCT
PCA
pCO2
PE
PEEP
PEP
PEG
PERRLA
Pess
PFT
pH
P/hx
PICC
PIP
PJ
PKU
PO
POP
Post-op
PR
Prem.
Pre-med.
prn
Pre-op
Pt.
PPE
PU
Nurse controlled analgesia
Nebulised
Neonatal Emergency Transport Service
Nasogastric
Non-Hodgkin’s lymphoma
Non-insulin dependent diabetes mellitus
Nurse Initiated Medication
Non-invasive ventilation
At night
Neck of Femur
Nasopharyngeal Aspirate
Nodal Rhythm
Number
Non weight bearing
Oxygen saturation
Observation
On admission or on arrival
On examination
Oppositional defiant disorder
Orogastric
Ointment
Open Reduction Internal Fixation
Operating Rooms
Operating theatre
Description/meaning
Parity
Pressure Area Care
Pulmonary arterial hypertension
Peripheral blood stem cell transplantation
Patient controlled Anaelgesia
Partial Pressure of Carbon Dioxide
Pulmonary embolism
Positive end-expiratory Pressure
Positive expiratory pressure
Percutaneous Endoscopic Gastrostomy
Pupils equal, reactive, respond to light and
accommodation
Pessary
Pulmonary function test
Degree of acidity or alkalinity
Past history
Peripherally Inserted Central Catheter
Peak Inspiratory Pressure
Polyjoule
Phenylketonuria
Oral, By Mouth, orally
Plaster of Paris
Post-operative
Per rectum
Prematurity
Pre-operative medication
When required
Pre-operative
Patient
Personal Protective Equipment
Passed Urine
Type II Diabetes
Comment
Neurology use
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
PUO
PV
P&V
PWB
qid
RBC
Resp.
Rh
RIF
RIH
RLL
RLQ
RML
RNA
ROM
R/O
RSV
RTL
RTW
RUL
RUQ
Rx
RVOT
S (1-5)
SA
SAH
SaO2
S/B
SBR
SCI
SDH
SG
SLE
SIADH
SIDS
SIMV
SOB
SPA
SPOC
SPECT
SPONT
SSS
Stat
Subcut
Subling
Supp
SUDI
SVC
SVT
T-U-V
T (1-12)
tab
T&As
TB
TBI
Pyrexia of unknown origin
Per Vagina
Percussion and vibrations
Partial weight bearing
Four times daily
Red blood cells
Respiratory
Rhesus factor (SESIH = Rh –ve or Rh +ve)
Right iliac fossa
Right inguinal hernia
Right lower lobe (lung)
Right Lower quadrant
Right middle lobe (lung)
Ribonucleic acid
Range of Movement
Removal of
Respiratory Syncytial Virus
Reacts to light
Returned to Ward
Right upper lobe (lung)
Right upper quadrant
Treatment
Right ventricular outflow tract
Sacral vertebrae
Sexual Assault
Subarachnoid haemorrhage
Arterial oxygen saturation
Seen by
Serum Bilirubin
Subcutaneous injection
Subdural haematoma
Specific gravity
System Lupus erythematosus
Secretion of inappropriate antidiuretic hormone
Sudden infant death syndrome
Synchronised intermittent mandatory ventilation
Short of breath
Suprapubic aspiration
Standard Paediatric Observation Chart
Single photon emission computer tomography
Spontaneous
Sick sinus syndrome
Immediately and once only (statim)
Subcutaneous
Sublingual
Suppository
Sudden unexpected death in infancy
Superior vena cava
Supraventricular tachycardia
Description/meaning
Previously known as SIDS
Comment
Thoracic e.g. T2 fracture
Tablet
Tonsillectomy and adenoidectomy
Tuberculosis
Traumatic Brain Injury
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.
Policy No: 1/C/11:8061-01:00
Policy: Approved Abbreviation List for use in Medical Records
tds
Temp.
TENS
TFT
t/f or T/F
TKVO
TPN
TPR
TPT
TRAM
T2DM
U/A
UEC
U/O
URTI
U/S
UTI
UWSD
VBG
VEB
VF
VQ scan
VUJ
VUR
VUTD
VV
W–X–Y–Z
WBAT
WBC
WCC
Wt
Three times daily
Temperature
Transcutaneous Electrical Nerve Stimulation
Thyroid Function Test
Transfer
To keep vein open
Total parenteral nutrition
Temperature, pulse, respiration
Trans Pyloric Tube
Tranvenous rectus abdominis myocutaneous flap
Type 2 diabetes Mellitus
Urinalysis
Urea, electrolytes, creatinine
Urine Output
Upper respiratory tract infection
Ultrasound
Urinary tract infection
Under water seal drain
Venous Blood Gas
Ventricular ectopic beats
Ventricular fibrillation
Ventilation perfusion scan
Vesico ureteric junction
Vesico ureteric reflux
Vaccinations up to date
Varicose vein
Description/meaning
Comment
Weight Bearing as tolerated
White blood cells
White cell count
Weight
Copyright notice and disclaimer:
The use of this document outside The Children's Hospital at Westmead (CHW), or its reproduction in
whole or in part, is subject to acknowledgement that it is the property of CHW. CHW has done
everything practicable to make this document accurate, up-to-date and in accordance with accepted
legislation and standards at the date of publication. CHW is not responsible for consequences arising
from the use of this document outside CHW. A current version of this document is only available
electronically from the Hospital. If this document is printed, it is only valid to the date of printing.
Date of Publishing: 23 December 2011 2:37 PM
Date of Printing: 23 December 2011
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This Policy/Procedure may be varied, withdrawn or replaced at any time. Compliance with this Policy/Procedure is mandatory.