Approved Abbreviations PDF
Preview Approved Abbreviations
Procedure Procedure on Approved Abbreviations for Use in the Health Care Record Date Created: 7June 2010 Last Updated: 7June2010 Version 1.0 Copyright SWAHS Page 1 of 84 Procedure on Approved Abbreviations for Use in the Health Care Record Date Created: Last Updated: 7 June 2010 Sydney West Area Health Service Table of Contents Symbols ............................................................................................................................... 5 General Abbreviations ......................................................................................................... 7 Abbreviations for Prescribing and Administering Medicines .............................................. 63 Nutrition Related Abbreviations ......................................................................................... 67 Therapy Related Abbreviations ......................................................................................... 69 Service/Role Related Abbreviations .................................................................................. 78 Copyright SWAHS Page 2 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service Purpose It is a requirement of NSW health policy1 and the SWAHS Procedure on Clinical Documentation in the Health Care Record that only abbreviations and symbols approved for use by SWAHS are used to document in the health care record. The purpose of this procedure is to To mandate a standard set of abbreviations that are permitted to be used in clinical documentation in SWAHS. To provide a standard level of documentation in SWAHS that is consistent across discipline and facility. This procedure is intended to be read in conjunction with the SWAHS Procedure on Clinical Documentationin the Health Care Record. Scope This procedure applies to all clinical, nursing, allied and other staff who are required to document in the patient/client health care record – whether it isin electronic or paper-based format. It applies across all inpatient, outpatient and community health settings. Note: The abbreviations contained within this proceduremust not to be used on Death Certificates. Definitions For the purposes of this procedure, the following key definitions and acronyms apply. In this document, the term: Must – indicates a mandatory action required by a NSW Health policy directive, law or industrial instrument. Should – indicates an action that is to be followed unless there is justifiable reasons for taking a different course of action. May – a suggested course of action that might assist in compliance with recordkeeping dependent on local requirements. Electronic Records Records created, communicated and maintained by means of electronic equipment2 Health Care Record A type of corporate record that is a documented account of a patient/client’s health, illness and/ or treatment during each visit or stay at a hospital, nursing home, PC&CH centre or related area health care facility in a hard copy or electronic form. The record is used to care for the patient/client during an episode of care but may also be used for future episodes of care, communication with external health providers and regulatory bodies, planning, research, education, financial reimbursement, quality improvement and public health. 1 NSW Health PD2005_127 – Records, Principles for Creation, Management, Storage and Disposal of Health Care Records, 25 January 2005, page 7 2 Cited by State Records Authority of NSW, Standard on Full and Accurate Records, p.11, as a reference taken fromAustralian Standard AS ISO 15489 Part 1 Clause 3.10 Copyright SWAHS Page 3 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service The health care record may also become an important piece of evidence in protecting the legal interests of the patient/client, clinician or health service. The health care record may be in hard copy, electronic or both. The provisions of this procedure apply equally to both paper based and electronic medical records. Where a health care record exists in both paper and electronic form this is known as a hybrid record. For further information about the hybrid medical record refer to SWAHS Hybrid Medical Record Policy. Patient/Client Any person who receives services from health care facilities in NSW. Either term may be chosen for use, depending on the context of health care provision. For the purposes of this standard, the term patient/client is used. Procedure 1 Approved Abbreviations and Symbols On the following pages is a list of a standard set of abbreviations that are permitted to be used in clinical documentation in the health care record. For ease of reference these abbreviations have been separated into the following categories Symbols General abbreviations Medication/drug related abbreviations Therapy related abbreviations Service/role related abbreviations. Note: Where there is more than one of the same abbreviation in this approved list, health care context will indicate which abbreviation is appropriate for use. Where more than one of the same abbreviation exists and the health care context does not assist in determining appropriate use, the abbreviation has not been included in this procedure as an approved abbreviation and is required to be written in full. Copyright SWAHS Page 4 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service Symbols Abbreviation/ Symbol Meaning/ Explanation @ At & And Increased or Up Decreased or Down Transverse Right (physio) Transverse Left (physio) = Equals ≠ Is not equal to # Fracture approximately ≈ ♂ Male ♀ Female +ve Positive -ve Negative ∆ Diagnosis Ψ Psychiatric With /60 Indicating minutes /7 Indicating days /12 Indicating Months /24 Indicating hours /40 Indicating gestation in weeks /52 Indicating weeks 1/365 Daily/ Day 10 First degree, primary 20 Second degree, secondary 30 Third Degree, tertiary + Slight Trace ++ Trace +++ Moderate trace ++++ Large Trace - Absent ® or ® or R Right (L) or L or L Left < Less than Copyright SWAHS Page 5 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service Symbols Abbreviation/ Symbol Meaning/ Explanation > More than Without Therefore ° (superscript) No, no history of % Percent ? Doubtful, questionable, query Degrees Celsius ˚c w/in or c’/ in Within α1- ATD Alpha1- antitrypsin deficiency Copyright SWAHS Page 6 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service General Abbreviations Abbreviation/ Symbol Meaning/ Explanation A A/ Assessment a/a As above AA Alcoholics Anonymous A1, A2 Aortic Valve, 1st sound, 2nd sound AAA Abdominal Aortic Aneurysm AAL Anterior – Axillary Line AB Apex Beat Ab Antibody Abdo Abdominal ABG/s Arterial Blood Gas(es) ABI Acquired Brain Injury/Impairment ABS Acute Brain Syndrome AC Acromioclavicular (joint) ACA Anterior Cerebral Artery ACC Acute Care Certificate ACL Anterior Cruciate Ligament ACM Ambulatory Cardiac Monitoring ACS Acute Coronary Syndrome ADC AIDS Dementia Complex ADD Attention Deficit Disorder ADH Antidiuretic Hormone ad lib Ad Libitum; as desired Add Adduction ADHD Attention Deficit Hyperactivity Disorder ADL Activities of Daily Living Adm Admission/Admitted ADR Adverse Drug Reaction ADRAC Adverse Drug Reactions Advisory Committee AE Air Entry AEA Above Elbow Amputation AEB Atrial Ectopic Beat A/F or AF Artificially Feeding Copyright SWAHS Page 7 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service General Abbreviations Abbreviation/ Symbol Meaning/ Explanation AF Atrial Fibrillation/ Flutter AF Activity Factor AFB Acid Fast Bacilli AFLP Acute Fatty Liver of Pregnancy AFO Ankle Foot Orthosis AFP Alpha Fetoproteins Ag Antigen AGN Acute Glomerulonephritis AH Abdominal Hysterectomy AHD Arteriosclerotic/Atherosclerotic Heart Disease AHF Anti- Haemophiliac (Factor VIII) AI Aortic Incompetence AICD Automatic Implantable Cardiac Defibrillator AIDS Acquired Immune Deficiency Syndrome AIH Autoimmune Hepatitis AIVR Accelerated Idioventricular Rhythm AJ Ankle Jerk AKA Above Knee Amputation/Also Known As ALA Assisted Local Anaesthetic Alb Albumin ALD Alcoholic Liver Disease ALF Acute Liver Failure ALG Anti- Lymphocytic Globulin ALL Acute Lymphoblastic/Lymphocytic/Lymphoid Leukaemia ALP (Alkphos) Alkaline Phosphotase ALS Amyotrophic Lateral Sclerosis ALT Alanine–Amino Transferase Alt Sl (ALT SL) Alternate Side Lying am/a.m Morning AMA Anti-mitochondrial Antibody AMD Age related Macular Degeneration AMI Acute Myocardial Infarct AML Acute Myeloid Leukaemia AMP Austin Moore Prothesis Amp Ampere Copyright SWAHS Page 8 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service General Abbreviations Abbreviation/ Symbol Meaning/ Explanation AMRI Anteromedial Rotary Instability AN Antenatal Anaes Anaesthetic ANA Antinuclear Antibody ANCA Anti-Neutrophil Cytoplasmic Antibodies Angio Angiocardiography ANLL Acute Non-Lymphocytic Leukaemia ANS Autonomic Nervous System Ant Anterior Anti- LKM Ab Anti-Liver/ Kidney Microsomal Antibody AODM Adult Onset Diabetes Mellitus AP Antero-Posterior APC Activated Protein C APC Argon Plasma Coagulation APC Adenomatous Polyposis Coli APH Antepartum Haemorrhage APL Abductor Pollicis Longus APO Acute Pulmonary Oedema Appt. Appointment APR Abdomino Perineal Resection APTT Activated Partial Thromboplastin Time ARBD Alcohol Related Brain Damage ARC AIDS Related Complex ARDS Adult Respiratory Distress Syndrome ARF Acute Renal Failure ARM Artificial Rupture of Membranes AROM ActiveRange of Movement ARV AIDS Related Virus AS Aortic Stenosis ASAP As Soon As Possible ASCA Anti-Saccharomyces Cerecisiae Antibody ASCVD Arteriosclerotic Cardiovascular Disease ASD Atrial Septal Defect ASHD Arteriosclerotic Heart Disease ASIS Anterior Superior Iliac Spine ASLR Active Straight Leg Raise Copyright SWAHS Page 9 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010 Sydney West Area Health Service General Abbreviations Abbreviation/ Symbol Meaning/ Explanation ASO Arteriosclerotic Obliterans AST Aspartate Amino Transferase ASVD Arteriosclerotic Vascular Disease AT Atrial Tachycardia ATN Acute Tubular Necrosis ATNR Asymmetrical Tonic Neck Reflex ATOR At Time Of Report ATS Antitetanus Serum ATSP Asked to See Patient Ausc. Auscultation AV Atrioventricular AV Arteriovenous AV Aortic Valve AVB Atrioventricular Block AVF Arteriovenous Fistula AVF Acute Ventricular Failure AVM Arteriovenous Malformation AVMs Arteriovenous Malformations AVN Atrioventricular Node AVN Avascular Necrosis AVO Apprehended Violence Order AVR Aortic Valve Replacement AVNRT Atrioventricular Nodal Re-entrant Tachycardia A&W Alive and Well A/W Associated With AWL/AWOL Absent Without Leave AWS Alcohol Withdrawal Syndrome Ax Assessment AXR Abdominal X- ray AZ Aschheim- Zondek test (for Pregnancy) Copyright SWAHS Page 10 of 84 Procedure on Approved Abbreviations for use in the Health Care Record Date Created: 7 June 2010 Last Updated: 7 June 2010
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