Accepted Abbreviations List PURPOSE

Transcription

Accepted Abbreviations List PURPOSE
Accepted Abbreviations List
PURPOSE
The purpose of the abbreviation list is to define recommended abbreviations that may be used in the
documentation of patient care within the CCEMS system.
Abbreviations are often used to facilitate and shorten written narratives. This is an acceptable practice as
long as it is universally recognized and understood abbreviations are used. The following are medical
abbreviations that are acceptable for use by EMS personnel in the CCEMSA region.
In situations where an abbreviation is not listed and the provider intends to use the abbreviation more
than once in the patient care report (PCR) the provider may spell out the complete term to be abbreviated
with the abbreviation immediately following the term enclosed in brackets (i.e., “()” ).
A.
Unlisted abbreviations that are acceptable to use are the following:
1) Hospitals, clinics or other medical facilities: When abbreviating facilities use the first letter of
each word of the proper title and only abbreviate the facility if it is already written in entirety
on the PCR as the response location or destination.
2) Fire: When abbreviating a fire department “FD” must follow any letters used to abbreviate the
city or municipality fire department.
3) Police: When abbreviating a police department or Police Officer response “PD” must follow
any letters used to abbreviate the city or municipality police department.
4) Sheriff: When abbreviating a sheriff department or Sheriff Officer “SO” must follow any letters
used to abbreviate the city or municipality sheriff department.
B.
Abbreviations acceptable to use on PCRs in the CCEMSA systems are listed as follows (see table
below).
&
?
^ or ∆
+
<
=
>
♀, F
♂, M
11-44
2nd, 3rd, etc.
5150
A/OX1,2,3,4
Abd
Abr
ACE
AED
A-fib
A-flutter
AICD
Accepted Acceptable Abbreviations
Negative, without, decrease
And
Possible, questionable
Change
Positive, with, increase
Less than
Equal
Greater than
Female
Male
Fatality or Deceased
Used when describing order
Danger to self, others, gravely disable with mental illness
Alert, and (1) Oriented to Person, (2) Place, (3) Time,
and (4) Event.
Abdomen
Abrasion
Angiotension converting enzyme
Automated External Defibrillator
Atrial Fibrillation
Atril Flutter
Automatic Internal Cardiac Defibrillator
AIDS
ALOC
ALS
AM
AMI
AOS
AMS
A-P
APAP
APGAR
ASA
ASHD
AU
AV
BG
BID
BLS
BM
BP
BVM
C/C
C/o
C1, C2
CA
Ca++
CABG
CAD
CALF
Cap
CBC
cc
CCU
chemo
CHF
CHP
cm
CNS
CO
CO2
COPD
CP
CPAP
CPR
CSF
CSMT
C-spine
CT or CAT
CVA
D/C
DNR
DOB
DOE
DT
Acquired immunodeficiency syndrome
Altered level of consciousness
Advanced life support
Morning
Acute myocardial infarction
Arrived On Scene
Altered mental status
Anteroposterior (front to back)
Acetaminophen
Appearance, Pulse, Grimace, Activity, Respiration
Acetylsalicylic acid
Arteriosclerotic heart disease
Both Ears
Atrioventricular
Blood glucose
Twice a day
Basic life support
Bowel movement
Blood pressure
Bag-valve-mask
Chief complaint
Complains of
First, Second, etc., cervical vertebra
Cancer or Carcinoma
Calcium
Coronary artery bypass graft
Coronary artery disease
CalFire*
Capsule
Complete blood count
Cubic centimeter
Coronary care unit
Chemotherapy
Congestive heart failure
California Highway Patrol*
Centimeter
Central nervous system
Carbon monoxide
Carbon dioxide
Chronic obstructive pulmonary disease
Chest Pain
Continuous Positive Airway Pressure
Cardiopulmonary resuscitation
Cerebral spinal fluid
Circulation, sensation, movement, temperature
Cervical precautions applied
Computed tomography (Scan)
Cerebrovascular accident
Discontinue
Do not resuscitate
Date of birth
Dyspnea on exertion
Delirium tremens
DVT
Dx
ECG or EKG
ED
EDC
EMS
EMT
EMT-P
ENT
ET or ETT
ETCO2
ETOH
FACTS
Fe
FHR
FHx
FR
FTB
Fx
gm
g
GB
GCS
GERD
GI
GPA
GSW
gtt(s)
GYN
H2O
HA
HBV
HCV
HIV
HPI
HSV-1, HSV-2
HTN
Hx
I&O
IC
ICP
ICU
IDDM
IM
IO
IV
IVDU
JVD
K+
KED
Kg
L1, L2
LA
Deep vein thrombosis
Diagnosis
Electrocardiogram
Emergency Department
Expected date of confinement
Emergency Medical Services
Emergency Medical Technician
Emergency Medical Technician - Paramedic
Ears, nose, throat
Endotracheal tube
End-Tidal Carbon Dioxide (level)
Ethyl alcohol
Mnemonic for: Focus, Activity, Color, Time (onset and
duration), and Supplemental history.
Iron
Fetal heart rate
Family history
First responder or French sizing
Full-Thickness Burn
Fracture
Gram
Gauge
Gallbladder
Glasgow coma score
Gastroesophageal reflux disease
Gastrointestinal
Gravida, Para, Abortus (i.e., G2, P1, A1)
Gunshot wound
Drop(s)
Gynecology
Water
Headache
Hepatitis B virus
Hepatitis C virus
Human immunodeficiency virus
History of present illness
Herpes simplex virus type 1 or 2.
Hypertension
History
Intake & output
Incident Commander
Incident Command Post
Intensive care unit
Insulin-dependent diabetes mellitus
Intramuscular
Intraosseous
Intravenous
Intravenous drug use
Juggler vein distention
Potassium
Kendrick Extrication Device
Kilogram (1000 grams)
First, second, etc., lumbar vertebra
Left atrim
Lat
LBBB
LLE
LLQ
LNMP
LOC
LP
LR
Lt
LUE
LUQ
LV
LVH
LVN
MAE
MCC
mcg
MD
MDMA
Meds or Med
meth
mg
MI
ml
mm
MOI
MRI
MRSA
MS
MVC
N/V/D
NA
Na+
NC
NIDDM
NKA
NKDA
NP or FNP
NPA
NPO
NRB
NRS
NS
NSAID
NSR
NTG
O.D.
O.S.
O.U.
O2
OA
OD
OOS
Lateral
Left bundle branch block
Left lower extremity
Left lower quadrant
Last normal menstrual period
Loss of consciousness
Lumbar puncture
Lactated ringers
Left
Left upper extremity
Left upper quadrant
Left ventricle
Left ventricular hypertrophy
Licensed vocational nurse
Moves all extremities
Motor cycle collision
Micrograms
Medical Doctor
3,4-Methylenedioxymethamphetamine commonly known
as Ecstasy
Medications
Methamphetamine
Milligram (1/1000 gram)
Myocardial infarction
Milliliter (1/1000 liter)
Millimeter (1/1000 meter)
Mechanism of injury
Magnetic resonance imaging
Methicillin-resistant Staphylococcus aureus
Morphine sulfate
Motor vehicle collision
Nausea, vomiting, diarrhea
Nerve Agent (Tabun, Sarin, Soman, GF, VX)
Sodium
Nasal cannula
Non-insulin dependent diabetes
No known allergies
No known drug allergies
Nurse practitioner / family nurse practitioner
Nasal pharyngeal airway
Nothing by mouth
Non-rebreather
Numeric Rating Scale (1-10) (1= Low, 10=High)
Normal saline
Non-steroidal anti-inflammatory drug
Normal sinus rhythm
Nitroglycerin
Right eye
Left eye
Both eyes
Oxygen
Osteoarthritis
Overdose
Out of Service
OPA
OPQRST
P
PA
PAC
PASTE
PASTMED
PE
PEA
PERRL
PFSH
PID
PM
PMD
PMH
PN
PND
PNS
POP
PRN
Pt
PTA
PTB
PVC
Q
QH
QID
Resp.
RR
R/O
RA
RBBB
RBC
RLE
RLQ
RMCT
RN
ROM
ROS
RSV
Rt
RUE
RUQ
RV
Rx
S/S
SA
SAMPLE
Oral pharyngeal airway
Mnemonic for: Onset, Provoke, Quality, Radiates,
Severity, and Time.
Pulse
Physician assistant
Premature atrial contraction
Mnemonic for: Progression, Associated chest pain,
Sputum, Time, Exertion.
Mnemonic for: Provocation, Associated chest pain,
Sputum (color and amount), Time, Medications, Exertion,
and Diagnosis.
Physical examination or pulmonary embolism
Pulseless electrical activity
Pupils equal, round, and reactive to light
Mnemonic for: Past, Family and Social History
Pelvic inflammatory disease
Afternoon
Primary medical doctor
Past medical history
Pain
Paroxysmal nocturnal dyspnea
Peripheral nervous system
Pain on palpation
As needed
Patient
Prior to arrival
Partial-Thickness Burn
Premature ventricular contraction
Every
Each hour
Four times a day
Respirations
Respiratory Rate
Rule out
Rheumatoid arthritis or Right Atrium
Right bundle branch block
Red blood cell
Right lower extremity
Right lower quadrant
Refusal of medical care and/or transport
Registered nurse
Range of motion
Review of symptoms
Respiratory syncytial virus
Right
Right upper extremity
Right upper quadrant
Right ventricle
Prescription
Signs and symptoms
Sinoatrial node
Mnemonic for: Signs and symptoms, Allergies,
Medications, Past history, Last oral intake, Events
leading up to.
Sc or Sq
SL
SLUDGEM
SNF
SOAP
SOB
SpO2
START
Stat
STB
STD
STEMI
Strep
Sx
T or Temp.
T1, T2
TA
Tab
TB
TC
TIA
TID
TKO
Trans
TTJI
Tx
Unk
URI
UTL
V/S
VF
VT or V-Tach
W/ or C_Bar
W/O or S_Bar
WBC
WMD
WNL
X
Y/O
Subcutaneous
Sublingual
Mnemonic for: Salivation, Lacrimation, Urination,
Defecation, Gastrointestinal distress, Emesis and Miosis.
Skilled nursing facility
Mnemonic for: Subjective, Objective, Assessment, and
Plan.
Shortness of breath
Oxygen Saturation of peripheral Hgb
Simple Triage and Rapid Treatment
Immediately
Superficial-Thickness Burn
Sexually transmitted disease
S-T elevation myocardial infarction
Streptococci (bacteria)
Symptoms
Temperature
First, second, etc., thoracic vertebra
Traffic Accident
Tablet
Tuberculosis
Traffic Collision
Transient ischemic attack
Three times a day
To keep open
Transport
Transtracheal jet insufflation
Treatment
Unknown
Upper respiratory infection
Unable to locate
Vital signs
Ventricular fibrillation
Ventricular tachycardia
With, C_Bar is a “C” with a line over.
Without, S_Bar is a “S” with a line over.
White blood cell
Weapon of mass destruction
Within normal limits
Times (used as multiplication sign)
Year(s) old
* The California Highway Patrol (CHP) and CalFire (CALF) have specific abbreviations because
their response areas are in the entire CCEMSA region; hence they are not covered in section A of
the listed abbreviations.