Abbreviations Acronyms and Clinical Coding Symbols 07Oct18 PDF

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Title: Department Approved by

Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Deputy Chief Financial Officer

GUIDELINE

Purpose This guideline is intended as a reference for health professionals to make effective use of their time, by providing a list of consistent abbreviations for the use in clinical documentation at Barwon Health. Where abbreviations are used they must be consistent and easily interpreted by clinical staff. Thus, the use of abbreviations and symbols other than those contained within this guideline are discouraged due to the potential for misinterpretation. All health professionals have a responsibility for ensuring clinical documentation that they produce, is of a standard that provides for effective ongoing care of the patient as well as meeting our legal obligations. Please note: these abbreviations are not applicable when documenting medicines information. For recommended terms and acceptable abbreviations for medicines information refer to: Approved Abbreviations for Communicating Medicines Information

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Symbols o

…… Ψ ↑ ↓ ↑↑ ↓↓ † ♀ ♂ 1º 2º 3º 1 /24 1 /7; 1/365 1 /52 1 /12 12 /40 /c < > ≤ ≥ = ≠ ≈ + ++ +++ ++++ +; +ve -; -ve Δ Ø 1x

‘no’ psychiatry / psychology up; increase(d); increasing; elevated, improved, raised down; decrease(d); decreasing; diminished; deficiency, worsened, lower testes undescended testes descended deceased Female Male primary; first degree secondary; second degree Tertiary; third degree 1 hour 1 day 1 week 1 month 12 weeks pregnant With less than greater than Less than or equal to Greater than or equal to Equal Not equal approximately and; increased; plus; positive; present; slight trace moderate; trace increased; moderately active; moderately severe large amount; severe positive negative change no; none One

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Title: Department Approved by 2x # @ Ō 4PS 4WF 2WF 3WF 6MWT // / * ✓ ✓✓ stick figures 1st Ray ? %; %age °C %ile °masses etc °nausea ∴

Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Twice fracture; number At Oral 4 point stick 4 wheeled frame 2 wheeled frame 3 wheeled frame 6 minute walk test reassessment per highlights the main findings on subjective or objective examination, reassess main effects of treatment (Physio) full active range of movement, no pain full active range of movement, no pain with over pressure sit to stand, lie to sit, etc (physiotherapy) First ray Query percentage Degrees celsius percentile No masses detected No nausea etc. Therefore

Abbreviations and Acronyms

A A; a; a; α a. ā A; Å A A or a A A1; A1 A2; A2 A2P2 a.a.; aa.

AA a/a AAROM AAA AB words AAC

Alpha artery (arteria) before (ante) angstrom unit assessment Alert Assist/ assistance Action (as part of S.O.A.P documentation) aortic valve - first sound aortic valve - second sound aortic second sound less than pulmonary second sound aortic second sound greater than pulmonary second sound of equal parts of each (ana) arteries (arteriae) alcoholics anonymous Auditory Alone (audiology) as above Assisted active range of movement abdominal aortic aneurysm Arthur Boothroyd words (audiology) acute angle closure

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms AACG AAI AAL AAPVT AAU AAVC Ab AB A&B Abs’; AB’s Abx Abd Abdo ABE ABG; ABGs AbH ABI ABLB AB6LICS ABMT Abn ABND ABNF ABNP Abort ABP ABPA ABPI ABR A/B ratio ABS AB words Ac AC

a/c; ac ACAS ACAT ACBT ACC ACCR

alternative augmentative communication acute angle closure glaucoma Atrial Paced; Atrial Sensed and Inhibited anterior axillary line Ammons & Ammons Picture Vocabulary Test acute anterior uveitis accessory atrioventricular conduction Abnormal antibody; antibodies aortic beat apex beat Apnoea and Bradicardia Antibiotics Abduction Abdomen acute bacterial endocarditis Arterial blood gas(es) Abductor Hallucus acquired brain injury ankle-brachial index alternate binaural loudness balance apex beat in 6th left intercostal space autologous bone marrow transplant Abnormal apex beat not displaced apex beat not felt apex beat not palpable Abortion Arterial blood pressure Allergic bronchopulmonary aspergillosis ankle brachial pressure index auditory brainstem response acid-base ratio Australian Bureau of Statistics acute brain syndrome Arthur-Boothroyd words Acute acromioclavicular (joint) air conduction alternating current anterior chamber (ophthalmology) Axiocervical associated with Aged Care Assessment Service Aged Care Assessment Team active cycle of breathing technique acinic cell carcinoma adrenocortical carcinoma Aged Care Client Record

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms ACCS ACD ACDF ACE ACE Inhibitor; ACE-I ACF ACG ACH ACHI ACI ACL ACN ACP ACP/D ACS

ACT ACTH AD ADAPT ADD Add. ADDH Addit: ADEM ADH ADHD ADI ADL Adm ADON ADPKD ADS ADR ADx AE

A&E AEA AF

alternating, convergent, concomitant strabismus Advanced Care Directive anterior cervical discectomy and fusion angiotensin converting enzyme angiotensin converting enzyme inhibitor anterior cervical fusion angiocardiography aortocoronary graft adrenocortical hormone after coming head Australian Classification of Health Interventions acute coronary infarction anterior cruciate ligament associate charge nurse Advanced Care Planning or Plan- depending on context Advanced Care Planning/Directive acute coronary syndrome alternating convergent strabismus Australian Coding Standards Automatic Clotting Time adrenocorticotropic hormone accident diary Axillary Dissection Alcohol, Drugs and Pregnancy Team attention deficit disorder Adduction attention deficit disorder with hyperactivity Addition/al acute demyelinating encephalomyelopathy antidiuretic hormone attention deficit hyperactivity disorder AIDS defining illness(es) activities of daily living admission / admitted Assistant Director of Nursing autosomal dominant polycystic kidney disease alcohol dependence syndrome alternating divergent strabismus Adverse Drug Reaction additional diagnosis above elbow adverse event air entry atrial ectopics accident and emergency above elbow amputation activity factor atrial fibrillation atrial flutter

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms A/F AFB AFI AFO AFP Ag Aggs AGA AGL AGN Ag NO3 AGTT AH AHA

AHD AHF AHLO AHMS AI AICD AID AIDS AIH AIHA AIHW AIIS AIMS AIN AIP AIS AJ A-K; AK AKA AKPOP ALCAPA ALCC ALD

Autoflow (Ventilation) artificial feed Aortofemoral bypass acid fast bacilli(us) Amniotic fluid index (maternity services) ankle foot orthosis alpha fetoprotein Antigen Aggravating factors average / appropriate for gestational age acute granulocytic leukaemia acute glomerulonephritis silver nitrate abnormal glucose tolerance test abdominal hysterectomy Australian hearing (audiology) acquired haemolytic anaemia acute haemolytic anaemia autoimmune haemolytic anaemia Allied Health Assessment autoimmune haemolytic disease acute heart failure Aboriginal Hospital Liaison Officer area mental health services aortic incompetence aortic insufficiency artificial insemination automatic implantable cardioverter / defibrillator artificial insemination by donor automatic implantable defibrillator acquired immune deficiency syndrome artificial insemination by husband autoimmune haemolytic anaemia Australian Institute of Health and Welfare anterior inferior iliac spine Agency Information Management System acute interstitial nephritis acute intermittent porphyria Abbreviated Injury Scale ankle jerk ankle joint above knee above knee amputation also known as above knee plaster of Paris anomalous left coronary artery and pulmonary artery Andrew Love Cancer Centre alcoholic liver disease assistive listening device

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms Alk ALL ALMI ALND ALP ALS Alt ALT ALTE alt. nocte a.m. AMA Amb AmpC AMI AML AMML AMP A/N AN ANA ANC ANLL ANS Ant Ante anthro. Anti D ANUM AO A&O AODM AOL AOM AOR AP

AP (resection) APATT APB APC APD

Alkaline acute lymphoblastic / lymphocytic leukaemia anterior lateral myocardial infarction Axillary Lymph Node Dissection alkaline phosphatase advanced life support Alternate alanine aminotransferase alanine transaminase apparent life threatening event every other night(alternis nocte) before noon; morning (ante meridiem) advanced maternal age against medical advice Ambulation Plasma medicated Amp C b-lactamase acute myocardial infarction acute myeloid / monocytic / myeloblastic / myelocytic leukaemia acute myelomonocytic leukaemia Austin Moore prosthesis Amplification (audiology) Antenatal avascular necrosis antinuclear antibodies antenatal clinic / care acute non-lymphocytic leukaemia autonomic nervous system Anterior Before anthropometry Rh (D) immunoglobulin Associate Unit Nurse manger Admitting Officer Alert and orientated adult onset diabetes mellitus augmentation of labour acute otitis media at own risk angina pectoris (Cardiology) anterior pituitary Anteroposterior arterial pressure Abdominoperineal (resection) Aged Psychiatric Assessment and Treatment Team atrial premature beat argon plasma coagulation atrial premature complex Accredited Practicing Dietician

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms

APH APL APLS APMHT APO APP APPT APR APTT/aPTT Ar AR ARBD ARBIAS ARC ARD ARDS ARF ARI ARM AROM ARPKD ART ARV AS

ASA ASAP ASCIA ASD ASIS ASO ASOM ASSR AT ATFL ATGAM ATN

atrial premature depolarisation aminohydroxypropylidene diphosphonate (pamidronate) Automated Peritoneal Dialysis Auditory Processing Disorder antepartum haemorrhage abductor pollicus longus (muscle) Advanced paediatric Life Support Aged Persons Mental Health Team acute pulmonary oedema as per protocol Appointment Abdominoperineal resection Auropalpebral reflex (audiology) activated partial thromboplastin time Argon aortic regurgitation artificial respiration alcohol related brain damage Alcohol Related Brain Injury Assessment Accommodation Support AIDS-related complex acute respiratory disease acute respiratory distress acute / adult respiratory distress syndrome acute renal failure acute respiratory failure acute renal impairment artificial rupture of membranes active range of movement artificial rupture of membranes autosomal recessive polycystic kidney disease assisted reproductive technology Adult Retrieval Victoria ankylosing spondylitis anterior synechiae aortic (valve) stenosis aortic sclerosis American Society of Anesthesiologists as soon as possible Australasian Society of Clinical Immunology and Allergy atrial septal defect autistic spectrum disorder anterior superior iliac spine arteriosclerosis obliterans acute suppurative otitis media auditory steady state response afternoon tea atrial tachycardia anterior talo fibular ligament Antithymocyte gamma globulin acute tubular necrosis

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms ATOR ATS ATSI ATSP ATW Aud Audio; Ausc AV

AVB AVF AVM AVN AVNRT AVR AVRT AVS A&W AWS Ax AXR

at time of report admission, transfer, separation Aboriginal and Torres Strait Islander asked to see patient admitted to ward Audiologist Audiogram Auscultation anteverted / anteversion (uterus) aortic valve Arteriovenous Atrioventricular Audiovisual (audiology) Ambulance Victoria atrioventricular block arteriovenous fistula atrioventricular failure arteriovenous malformation atrioventricular node avascular necrosis atrioventricular nodal re-entrant tachycardia aortic valve replacement atrioventricular reciprocating tachycardia aortic valve stenosis alive and well alcohol withdrawal syndrome / scale Axillary Web Syndrome assessment abdominal X-Ray

B B; β B Ba BA BAC B฀ D BAL Ba. Meal/enema BAWO BBA BBB BBBB BBE BBS BBT BC

beta twice (bis) barium back access bowel action blood alcohol concentration bipolar affective disorder blood alcohol level barium meal bilateral antrum washout born before arrival blood brain barrier bundle branch block bilateral bundle branch block Bilateral Basal expansion Bronchial Breathing Sounds basal body temperature blood culture bone conduction (audiology)

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms B&C BCA BCC BCE BCG BCPAP BCPS B cult; Bl cult b.d. BE

B/F BFG b/f; b/fast BG

BGL BHCG BIBA BIH

BIHR Bilat: Bili BIMA BIN BINA BINE BINS BiPaP; BIPAP BIPP BITA B-K; BK BKA BKPOP BL Bl BLS BM

BMA BMAT BMD BMI

Bellarine Centre breathing and coughing balloon catheter angioplasty basal cell carcinoma basal cell epithelioma bacille Calmette-Guérin (TB vaccine) Bubble Continuous Positive Airway Pressure bilateral cavopulmonary shunt blood culture twice per day (bis in die) basal expansion below elbow both eyes breastfed / breastfeeding Breakfast Grouup Breakfast blood gases blood glucose bone graft blood glucose level beta human chorionic gonadotropin brought in by ambulance benign intracranial hypertension bilateral inguinal hernia born in hospital bilateral inguinal hernia repair bilateral bilirubin bilateral internal mammary arteries binaural bilateral intranasal antrostomy bilateral intranasal ethmoidectomy bilateral intranasal sphenoidectomy bi-level positive airway pressure bismuth subnitrate, iodoform, liquid paraffin, packing gauze bilateral internal thoracic arteries below the knee below knee amputation below knee plaster of Paris blood loss blood basic life support bone marrow bowel movements breast milk bone marrow aspirate bone marrow aspirate and trephine benign mammary dysplasia bipolar mood disorder body mass index

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms BMR BMT BN BNI BNO BNR BO B/O BOA BOO BOOP BOS B&P BP BPD BPH BPIT BPM/bpm BPP BPPV BPSD BPV BR Bro BS BSA BSE BSGT BSL BSM BSO BSOM BSR BSSO BT BTE BTx BU

Barwon Medical Imaging basal metabolic rate bone marrow transplant bladder neck bladder neck incision bladder neck obstruction bowel not open bladder neck resection bowels opened baby of behavioural observation audiometry born on arrival bladder outflow obstruction bladder outlet obstruction bronchiolitis obliterans organising pneumonia base of skull base of support birth and pregnancy blood pressure borderline personality disorder Biparietal diameter (maternity services) bronchopulmonary dysplasia benign prostatic hypertrophy / hyperplasia bilateral partial intranasal turbinectomy Beats per Minute Bio physical profile (maternity services) Benign paroxylsmal positional vertigo behavioural and psychological symptoms of dementia benign positional vertigo Brachioradialis Breast Brother bowel sounds breath sounds body surface area breast self-examination Bilateral symmetrical and equal bilateral Shepherd’s grommet tympanotomy blood stained liquor blood sugar level bilateral suction / septal myringotomy bilateral salpingo-oophorectomy bilateral suppurative otitis media blood sedimentation rate bilateral sagittal split osteotomy bladder training blalock-taussig (shunt) Behind the ear (audiology) blood transfusion bulky uterus

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Abbreviations, Acronyms and Clinical Coding Symbols Health Information Services Chief Information Officer

GUIDELINE

Abbreviations and Acronyms BUDT BUN BVAD BVF BW b/w BWO

Bx

bilateral undescended testes blood urea nitrogen biventricular assist device bilateral ventricular failure birth weight Birdsy wing Between bladder washout bowel washout bowels well opened Biopsy

C ĉ Co C1-7 C c/-; c/o CI - CXII C1,C2 CA CAB CABG/s CACP CaCx CAD CADASIL (syndrome) CADD CADL CAG CAGS CAH

Ca in situ Cal CAL CALD CAM CAMHS cap CAP CAPD

with (cum) Centigrade cervical vertebrae 1-7 cancer; carcinoma cervical (spine) care of complains of cranial nerves 1-12 Cycle 1, Cycle 2 (Chemotherapy) cancer / carcinoma coronary artery Citizens Advice Bureau coronary artery bypass coronary artery bypass graft Community Aged Care Package cancer of the cervix coronary artery disease cerebral autosomal dominant arteriopathy with subcortical infarct and leukoencephalopathy (syndrome) continuous ambulatory drug delivery (device) community activities of daily living coronary artery graft Coronary angiogram coronary artery graft surger...