36C26219R0026-025.doc

VA Loma Linda Healthcare System

Healthcare System (HCS) Policy 136-04 Loma Linda, CA July 12, 2016

COMPLETION OF MEDICAL RECORDS

I.

POLICY: To assure that medical records contain sufficient information to support the diagnosis, describe the course of treatment, and include patient care evaluation studies and research (where applicable).

II.

RESPONSIBILITIES:

A. Clinical services and the attending physicians are responsible for ensuring the adequate and timely completion of medical records by the responsible health care professionals in their services. The established timelines for physicians to complete the medical records will be monitored as a physician’s evaluation factor and used for clinical privileging.

B.

The Health Information Management Section (HIMS) is responsible for ensuring the accurate and timely administrative processing of records and the Patient Treatment Files (PTF) information.

D.

Per VHA regulations, all clinicians are responsible for:

1. Honoring all requests by patients for the completion of non-VHA medical forms (with the exception of the completion of examination forms if a third part customarily pays the health care practitioners for the examination, but does not pay the VA). (Note:

The procedure used by resident physicians to complete medical records is outlined in Attachment A.)

2. Honoring all requests for the provision of medical statements and following the procedures established by the local facility’s Release of Information (ROI) Office.

III. PROCEDURES:

A. The primary medium for documentation of all patient care activities within VHA is the Computerized Patient Record System (CPRS), i-MED Consent, and VistA Imaging. Doctor’s Orders, consents, and all health care professionals’ progress notes will be entered electronically in CPRS, unless not technologically possible.

B. A complete History and Physical (H&P) Examination will be performed within the first twenty-four (24) hours of hospitalization on each admission, documented in CPRS and completed by a physician, oral surgeon, or podiatrist, as appropriate. Patients admitted for observation are the only exception to this policy. Patients admitted for observation may have the abbreviated H&P completed. This form must be completed within forty-eight (48) hours and is limited to hospitalizations of forty-eight (48) hours or less. If the patient’s stay is more than 48 hours, a full H&P must be completed. When, within a thirty (30) day period, an inpatient is readmitted for the same condition, the previous H&P Examination with an interval progress note will suffice. After two complete successive readmissions using an interval progress note, another H&P Examination must be performed and recorded unless the readmissions have been within the thirty (30) day period and have been for therapy only, e.g., transfusion.

C. Verbal and telephone orders when received by a licensed health care provider, within their scope of practice, will be considered official. The receiver of the order will write down the complete order or enter it into a computer, then read it back and receive confirmation from the individual who gave the order. This applies to all verbal or telephone orders except in emergency situations, such as Code Blues. In emergency situations, when the physician gives an order, the receiver of the order should repeat it back verbally prior to carrying out the order. It is the responsibility of the nurse and ordering provider to provide and obtain correct read back of the order. The practitioner giving the telephone or verbal orders will review/authenticate the order(s) within 24 hours.

HCS Policy 136-04

D.

Operation Reports will be dictated immediately following surgery (within 24 hours following surgery), transcribed and authenticated by the surgeon as soon as possible. Pending receipt of the completed transcribed Operation Report, a comprehensive post-op note will be written in the progress notes so that there will be sufficient information for proper post-operative care.

E.

Doctors' Orders and all health care professionals' progress notes will be entered electronically in CPRS, unless not technologically possible.

F.

Adequate controls will be instituted to ensure that the hospital operative reports are dictated as required. Health Information Management Section (HIMS) will advise the respective bed service chief's office of undictated and incomplete reports each week and prepare a report of Incomplete and Delinquent Records for the monthly Medical Executive Council meeting.

G.

Completion of Medical Records is included in the annual/bi-annual credential review process.

H.

The use of electronic encounter forms is mandatory. The diagnosis documented on the encounter form does not substitute for documenting the diagnosis in the note. Coding on the encounter form must be substantiated by the documentation in the practitioner’s note.

I.

Discharge Summaries:

1. Physicians will enter into CPRS at the termination of the patient’s hospitalization without the use of abbreviations. For patients who fail to return from pass (Community Living Center) and are discharged irregular and patient deaths, discharge summaries are encouraged to be entered into CPRS within 48 hours of the discharge or date of death, and no later than 30 days.

2. Need to be prepared for all releases from VHA care, including deaths. Transfer to other levels of care, such as: VHA domiciliary care, VHA nursing home, or other VHA medical centers, must be documented by a discharge summary. Appropriate ICD-10-CM diagnostic, procedures, and operative codes will be entered in the date column of SF 509 by Health Information Management Section (HIMS) personnel responsible for the medical records analysis and coding. Unit clerks will prepare a VA Form 10-1000 to serve as the "cover sheet" completing all items of an administrative nature. No signature is required on the form. The required entry in the "Summary" item will be as follows: "Refer to Progress Note date __________for summary, diagnosis, operations (if any) and ICD-10-CM code information."

J.

All medical records needing final signatures, additional entries or other documentation will be forwarded weekly to respective service chiefs for completion. Medical records must be completed within thirty (30) calendar days following the discharge of the inpatient.

K.

Administrative responsibilities including the quantitative review of the medical record, the identification and clear labeling of all required signatures should be performed by Health Information Management Section within ten (10) workdays after the patient has been discharged from the Medical Center.

IV.SUPPLEMENTAL INFORMATION:

A.

Definitions: None

B.

References: M-1, Part I, Chapter 5 and 26; Current Edition of Joint Commission Standards; VHA Handbook 1907.1; Medical Staff Bylaws, Current Version; VHA Directive 2008-071.

C.

Attachments:

Attachment A: Procedures for Resident Physician Completion of Medical Records.

Attachment B: Approved Medical Center Abbreviation and Symbols Lists V. COLLABORATED WITH: Associate Chief of Staff for Education, Chairman of the Clinical Informatics Committee; Health Information Manager; Chief of Quality Management; Patient Safety Manager; Medical Executive Council (MEC)

VI.

RESCISSION: HCS Policy 136-04 dated February 13, 2013

VII.

REVIEW AND REISSUE DATE: July 12, 2019 HCS Policy 136-04

VIII.

POLICY COORDINATOR: Chief of Health Information Management Section (HIMS)

//Original Signed//

BARBARA FALLEN, FACHE, DIRECTOR

Chair, Executive Leadership Board Attachment A

HCS Policy 136-04 Procedures for Resident Physician Completion of Medical Records

1. Each service is responsible for monitoring and assuring resident physician compliance with Health

Administration Service Policy 136-04, Completion of Medical Records. Reports of record deficiencies are sent to services from the Health Information Management Section (HIMS) regularly.

2. Service chiefs or their designee, in conjunction with HIMS, will review and track reports of incomplete records, particularly discharge summaries and provide notification to resident physicians regarding delinquencies. This review and tracking includes determining which house officer is responsible for the delinquent records since often times multiple resident physicians care for one patient. The attending physician may need to be contacted to determine the responsible resident physician.

3. Resident physicians must receive adequate notification and reminders to complete medical records. This may include telephone calls, letters and text pages. Resident physicians who do not respond in a timely manner or after several reminders should be warned that their names will be forwarded to the Office of the Associate Chief of Staff for Education (ACOS/E) should the medical record remain delinquent after 30 days.

4. If the medical record remains delinquent after 30 days, the service chief will forward the resident’s name to the Office of the ACOS/E. The ACOS/E’s Office will contact the resident physician with one final reminder and will issue a letter to the Loma Linda University Medical Center House Staff Office requesting suspension of the resident physician for incomplete medical records.

5. Suspension results in revocation of clinical privileges at all training sites which are restored only after the medical records are completed.

6. Attending physicians should be encouraged to include timely completion of medical records as part of their monthly evaluations.

Attachment B

APPROVED MEDICAL CENTER ABBREVIATION AND SYMBOL LISTS

The list of approved abbreviations and symbols as provided can be used by the staff of this Medical Center when making entries in the medical records. The dangerous abbreviations (HCS Policy 00-07 Patient Safety Plan – Attachment C) are not to be used when making any hand-written entries in the medical records.

Responsibilities:

All healthcare professionals who make entries in patient medical records are responsible for ensuring that they do not use the listed dangerous abbreviations and use only the approved abbreviations and symbols reflecting their assigned meanings.

TERMS AND ABBREVIATIONS APPROVED FOR USE IN THE PROCEDURES RELATING TO MEDICATION AND TREATMENTS - ALPHABETICAL ORDER

A A&A

Aid and Attendance

A&O

Alert and Oriented

AA

Authorized Absence

A-P

Anterior-Posterior

A2

Aortic component of the second heart sound

AAA

Abdominal Aortic Aneurysm

AAL

Anterior Axillary Line abd

Abdomen abg

Addictive behavior group

ABG

Arterial Blood Gas

AC

Acromioclavicular a.c.

Before meals accom

Accommodation

ACTH

Adrenocorticotropin Hormone

ADA

American Dietetic Association

ADD

Attention Deficit Disorder

ADH

Antidiuretic Hormone

ADHD

Attention Deficit Hyperactivity Disorder

ADL

Activities of Daily Living ad lib as much as desired admit

Admission

Adv

Advise

AFB

Acid Fast Bacillus

A/G ratio

Albumin-globulin ratio

AH

Auditory Hallucinations

AI

Aortic Insufficiency

AIDS

Acquired Immune Deficiency Syndrome

AIMS

Abnormal Involuntary Movement Disorder

A/K

Above Knee

AKA

Above Knee Amputation alb

Albumin alk

Alkaline a.m.

Morning

AMA

Against Medical Advice amb

Ambulatory amp

Ampule amt

Amount

AOD

Administrative Officer of the Day

AODM

Adult Onset Diabetes Mellitus

AP

Arterial Pressure

APC

Aspirin Phenacetin Compound(aspirin-caffeine) approx

Approximately appt

Appointment

APR

Abdominal Perineal Resection

AR

Aortic Regurgitation

ARDS

Adult Respiratory Distress Syndrome

AS

Aortic Stenosis

ASB

Anesthesia Stand By

ASA

Acetylsalicylic Acid (aspirin)

ASCVD

Arteriosclerotic Cardiovascular Disease

ASHD

Arteriosclerotic Heart Disease

ASI

Addiction Severity Index

ASO titre

Antistreptolysin 0 Titre

ASVD

Atherosclerotic Vascular Disease

ATN

Acute Tubular Necrosis

ATP

Addictions Treatment Program

ATU

Addictions Treatment Unit

A.V.

Arteriovenous

AWOL

Absent Without Leave

B Ba

Barium

Bacti Lab

Bacteriology Laboratory

Barb Level

Barbiturate Level (slang) basos

Basophils

B&B

Bowel and Bladder

B&C

Board and Care

BBB

Bundle Branch Block (Right or Left)

BE

Barium Enema

B.E.E.

Basal Energy Expenditure

BHIP

Behavioral Healthcare Intake Program

BHOST

Behavioral Healthcare Outpatient Services Team b.i.d.

Twice a day bilat.

Bilateral bili

Bilirubin

B/K

Below Knee

BKA

Below Knee Amputation

Bld chem.

Blood Chemistry

BM

Bowel Movement

BP

Blood Pressure

BPH

Benign Prostatic Hypertrophy

BP, P, R, T

Blood Pressure, Pulse, Respiration, Temperature

BRP

Bathroom Privileges

BS

Bowel Sounds

BSA

Body Surface Area

BUN

Blood Urea Nitrogen

BVA

Bioimpedence Venous Analysis

Bx

Biopsy

C C&P

Compensation and Pension

Cl, 2, 3, etc.

Cervical vertebrae 1, 2, 3, etc.

c

Celcious c

With

CA

Carcinoma

CABG

Coronary Artery Bypass Graft

CAD

Coronary Artery Disease cal

Calorie cap

Capsule

CAPD

Continuous Ambulatory Peritoneal Dialysis

CAT

Computerized Axial Tomography cath catheter

CBC

Complete Blood Count

CBS

Chronic Brain Syndrome ccu

Coronary Care Unit

CDTP

Chemical Dependency Treatment Program

CPRS

Computerized Patient Record System

CPS

Chronic Paranoid Schizophrenia

Child Protective Services

CGN

Chronic Glomerulonephritis

CHD

Coronary Heart Disease

CHF

Congestive Heart Failure

CHO

Carbohydrate chol

Cholesterol

CLL

Chronic Lymphocytic Leukemia

CM.

Centimeter

CNH

Community Nursing Home or Contract Nursing Home

CNS

Central Nervous System

C/0

Complains of comp

Compound cont

Continue

COPD

Chronic Obstructive Pulmonary Disease

CPK

Creatinine Phosphokinase

CPM Machine Continuous Passive Movement Machine

CPR

Cardiopulmonary Resuscitation

C&S

Culture and Sensitivity

CSF

Cerebrospinal Fluid

CTS

Carpal Tunnel Syndrome

CT Scan

Computerized Axial Tomography Scan cuc

Chronic Ulcerative Colitis

CVA

Cerebrovascular Accident

CVD

Cardiovascular Disease

CVAT

Costovertebral Angle Tenderness

CVP

Central Venous Pressure cysto

Cystoscopy

CXR

Chest X-Ray

D D&C

Dilatation and Curettage

DDD

Degenerative Disc Disease decub.

Decubitus

Derm

Dermatology

DES

Diethylstilbesterol

Diast.

Diastolic

DIC

Disseminated Intravascular Coagulation

Diff.

Differential disch

Discharge

DJD

Degenerative Joint Disease

DKA

Diabetic Keto-Acidosis

DM

Diabetes Mellitus

DNR

Do Not Resuscitate

D/NS

Dextrose in Normal Saline

D/O

Disorder

DOA

Dead on Arrival

DOB

Date of Birth

DOE

Dyspnea on Exertion

DPT

Triple booster Diphtheria, Pertussis, Tetanus

DTR

Deep Tendon Reflexes

DTs

Delirium Tremens

DVT

Deep Venous Thrombosis

Dx

Diagnosis

DYSFNX

Dysfunction

Dz

Disease

D5W

Dextrose 5% in Water

E

EBL

Estimated Blood Loss

ECG-EKG

Electrocardiograph

ECT

Electroconvulsive Therapy

E. coli

Escherichia coli

EDW

Estmated Dry Weight

EEG

Electroencephalograph elix

Elixir

EMG

Electromyograph

EMT

Emergency Medical Technician

ENT

Ear, Nose, and Throat

EOM

Extraocular Muscles

Eosins

Eosinophils

ER

Emergency Room

ERCP

Endoscopic Retrograde Cholangio-Pancreatoraphy

ESR

Erythrocyte Sedimentation Rate

Est

Estimated

ETOH

Ethyl alcohol

Exam

Examination

F F

Fahrenheit

FB

Foreign Body fb

Fingerbreadth

FBS

Fasting Blood Sugar

FDP

Flexor Distal Phalanx fld

Fluid fld. ext.

Fluid extract fld. rest.

Fluid restriction ft.

Foot

FTSG

Full Thickness Skin Graft

FU

Follow-Up

FUO

Fever of Undetermined Origin

Fx

Fracture G

GAD

Generalized Anxiety Disorder

GAF

Global Assessment of Functioning gal

Gallon

GB

Gallbladder

GB series

Gallbladder series

GC

Gonorrhea

GI

Gastrointestinal

GERD

Gastroesophageal Reflux Disorder

Glu

Glucose gm

Gram gr

Grain gtt

Drop

GTF

Gastrostomy Tube Feeding

GTT

Glucose Tolerance Test

GU

Genitourinary

GYN

Gynecology H

HAA

Hepatitis Associated Antigen

HB

Housebound

HBCM

Hospital Based Case Management

HBP

High Blood Pressure

HCVD

Hypertensive Cardiovascular Disease

Hct

Hematocrit

HEENT

Head, Ears, Eyes, Nose & throat

Hgb

Hemoglobin

HH

Hiatal Hernia

HI

Homicidal Ideation

HNP

Herniated Nucleus Pulposus

H&P

History and Physical Examination

HPI

History of Present Illness h.s.

At bedtime

2 hr. pp

2 hours postprandial

Ht

Height

HTN

Hypertension

HCS 136-04

hx

History hyper-al

Hyperalimentation solution with hyperalimentation

Hyst

Hysterectomy

I I-123

Radioactive iodine isotope (123)

I-125

Radioactive iodine isotope (125)

I-131

Radioactive iodine isotope (131)

IBW

Ideal Body Weight icu

Intensive Care Unit

I&D

Incision and Drainage

IDDM

Insulin Dependent Diabetes Mellitus

IHSS

Idiopathic hypertrophic Subaortic Stenosis

I.M.

Intramuscular in.

Inches info

Information

I&O

Intake and Output

IOL

Intraocular Lens

IPJ

Interphalangeal Joint

IPK

Interphalangeal Keratosis

IPPB

Intermittent Positive Pressure Breathing

IT

Intertrochanteric

IUF

Isolated Ultrafiltration

I.V., iv

Intravenous Infusion

IVP

Intravenous Pyelogram

IVPB

Intravenous Piggyback

J

JVD

Jugular Venous Distention K K

Potassium kg

Kilogram

Kcal

Kilocalorie

KUB

Kidneys, Ureters, Bladder (Radiology film of)

KUF

Kidney Ultrafiltration Rate

L LI, 2, 3, etc.

Lumbar vertebra 1, 2, 3, etc.

L

Left l liter

LA

Left Atrium lab

Laboratory lat lateral

LBBB

Left Bundle Branch Block lb

Pound

LBP

Low Back Pain

LCM

Left Costal Margin

LE

Lower Extremities

LLL

Left Lower Lobe of Lung

LLQ

Left Lower Quadrant

LLVAH

Loma Linda Veterans Administration Hospital

LLUMC

Loma Linda University Medical Center

LOA

Left Occiput Anterior

LOC

Level of Consciousness

LP

Lumbar Puncture

LPM

Liter Per Minute lq

Liquid

L-S

Lumbosacral

LS Scan

Liver Spleen Scan

LSB

Left Sternal Border

LUL

Left Upper Lobe of Lung

LV

Left Ventricle

LVH

Left Ventricular Hypertrophy

LVN

Licensed Vocational Nurse lymphs

Lymphocytes

M

MAL

Midaxillary Line

MAOI

Monoamine Oxidase Inhibitor mcg micrograms

MCL

Midclavicular Line

M.D.

Medical Doctor meds

Medicines and medications mEq

Milliequivalents mg milligram mi

Myocardial Infarction min

Minute ml

Milliliters mm

Millimeters

MMSE

Mini-Mental Status Examination mom

Milk of Magnesia monos

Monocytes

MP

Metacarpophalangeal (joint)

MR

Mitral Regurgitation

MRI

Magnetic Resonance Imaging

MSE

Mental Status Examination

MVA

Motor Vehicle Accident mvi

Multiple Vitamin Infusion

MVP

Mitral Valve Prolapse

N Na

Sodium

NAD

No Acute distress

N2

Nitrogen

N/C

Nasal Cannula

NCV

Nerve Conduction Velocity Study

NED

No Evidence of Disease

Neuro

Neurology

NG

Nasogastric

NGT

Nasogastric Tube

NID

Non-Insulin Dependent

NKA

No Known Allergies

NL (or WNL) Normal Limits (or Within Normal Limits) noc

Night

NOS

Not Otherwise Specified

NPH Insulin Neutral Protamine Hagedorn (Isophane Insulin)

NPO

Nothing by mouth

NS

Normal Saline

NSR

Normal Sinus Rhythm

NSU

Non-Specific Urethritis

NTG

Nitroglycerin nx

Nourishment

O

Orally

Oxygen

O&E

Observatioin & Examination

OBS

Organic Brain Syndrome

OCD

Obsessive-Compulsive Disorder

OPG

Oculoplethysmography

OPT

Outpatient Treatment

OPT-NSC

Outpatient Treatment/Nonservice-Connected

OPT-SC

Outpatient Treatment/Service-Connected

OR

Operating Room

ORIF

Open Reduction with Internal Fixation

Ortho

Orthopedics

O.S.

Left eye

OT

Occupational Therapy

OTC

Over-the-counter

O.U.

Both Eyes (in each eye) oz

Ounce

P P2

Pulmonic component of the second heart sound

PA

Posterior-Anterior

Pap Smear

Papanicolaou Smear

P&A

Percussion & Auscultation

PACT

Preservation Amputation Care and Treatment

PAR

Post-Anesthesia Recovery

PAS

Para-aminosalicylic Acid (or Pamisyl)

PAT

Paroxysmal Atrial Tachycardia

PBC

Pre-Bed Care p.c.

After meals

PCA

Patient Controlled Analgesia (Pumps)

PCT

Post-traumatic Stress Disorder Clinical Team

PD

Personality Disorder

P.E.

Physical Examination

PEG

Percutaneous Endoscopic Gastrostomy

PERRLA

Pupils, Equal, round, Reactive to Light and

Accommodation

PFT

Pulmonary Function Test

Phenobarb

Phenobarbital

PID

Pelvic Inflammatory Disease

PIP

Proximal Interphalangeal (Joint) p.m.

After 12 noon

PMD

Private Medical Doctor

PMH

Past Medical History

PMI

Point of Maximum Impulse

PND

Paroxysmal Nocturnal Dyspnea p.o.

By mouth

POD

Post-Op Day

Polio

Poliomyelitis polys (segs) Polymorphonuclear Segmented Neutrophils postop

Postoperative

P.P.

Post-prandial

PPD

Purified Protein Derivative (TB skin test)

PRA

Plasma Renin Activity

PRBC

Packed Red Blood Cells preop

Before surgery prep

Prepare

Pro

Protein

PROTIME

Prothrombin Time p.r.n.

As circumstances may require

PSCE

Presurgical Coagulation Evaluation

Psych

Psychiatry pt

Patient

PT

Prothrombin Time

PTSD

Post-Traumatic Stress Disorder

PTT

Partial Thromboplastin Time

PTA

Prior to Admission

PUD

Peptic Ulcer Disease

PVC

Premature Ventricular Contractions

PVD

Peripheral Vascular Disease

PZI

Protamine Zinc Insulin

Px

Physical Examination

Q q.h.

Every hour q2h, q3h, etc.

Every two hours, every three hours, etc.

q.i.d.

Four times a day q.n.s.

Quantity not sufficient

QRS

QRS complex of the ECG q.s.

A sufficient quantity

Q-S2

Interval of time from beginning of QRS complex to beginning of second heart sound

R

RA

Rheumatoid Arthritis

RAS

Renal Artery Stenosis

RBBB

Right Bundle Branch Block

RBC

Red Blood Count rect

Rectal rt, R

Right

RBS

Random Blood Sugar

RCM

Right Costal Margin

Re

Regarding

Reg diet

Regular diet

Retro. pyelo Retrograde pyelogram

RFS

Rapid Frozen Section

RHD

Rheumatic Heart Disease

RISA Scan

Radio-Iodinated Serum Albumin Scan

RLL

Right Lower Lobe of Lung

RLQ

Right Lower Quadrant

RML

Right Middle Lobe of Lung

RND

Radical Neck Dissection

R/O

Rule Out

ROA

Right Occiput Anterior

ROM

Range of Motion

ROS

Review of Systems

RSR

Regular Sinus Rhythm

R.T.

Recreation Therapy

R/T

Related Tb

RTA

Renal Tubular Acidosis

RTC

Return to Clinic

RUL

Right Upper Lobe

RUQ

Right Upper Quadrant

RVH

Right Ventricular Hypertrophy

RVT

Renal Vein Thrombosis

Rx

Treatment or take

S si

First heart sound

S2

Second heart sound

S3

Third heart sound

S4

Fourth heart sound

Sl, 2, 3, etc.

Sacral vertebra 1, 2, 3, etc. (or foramina) s

Without

SA

Sino-Atrial

SA

Suicide Attempt

S&A

Sugar & Acetone

SBE

Subacute Bacterial Endocarditis

SDAT

Senile Dementia - Alzheimer's Type sed. rate

Sedimentation rate sero

Serological examination for ...

Serol

Kahn, etc., serological examination

SGOT

Serum Glutamic Oxaloacetic Acid Transaminase

SGPT

Serum Glutamic Pyruvic Transaminase

SI

Suicidal Ideation

S.I.

Seriously Ill sig/sign

Signature

SLE

Systemic Lupus Erythematosus sm

Systolic Murmur

SMBG

Self Monitored Blood Glucose

SOB

Shortness of Breath soda bicarb Sodium bicarbonate

SOD

Surgical Officer of the Day sod. acid phos Sodium acid phosphate solv

Solvent

S/P

Status Post spec. diet

Special diet

SPEP

Serum Protein Electrophoresis

sp. gr.

Specific gravity

S/S

Signs and Symptoms

SSKI

Saturated Solution of Potassium Iodide

SSRI

Selective Serotonin Re-up Take Inhibitor

Staph

Staphylococcus

STAT

Immediately

STC

Sexual Trauma Clinic

STG

Split Thickness Graft

STJ

Subtalar Joint

Strep

Streptococcus

STSG

Split Thickness Skin Graft

Subcu

Subcutaneous

SUF

Sequential Ultrafiltration sx

Surgeries syst.

Systolic

T Tl, 2, 3, etc.

Thoracic vertebrae 1, 2, 3, etc. (or interspace)

T&A

Tonsillectomy & Adenoidectomy tab

Tablet

TAH

Total Abdominal Hysterectomy

TAT

Tetanus Antitoxin

TB

Tuberculosis tbsp or tbs Tablespoon

TCA

Tricyclic Antidepressant

TEM

Triethylene Melamine

TF

To Follow

TG

Triglycerides

THA

Total Hip Arthroplasty

TI

Tricuspid Insufficiency

TIAs

Transient Ischemic Attacks t.i.d.

Three times a day

TKA

Total Knee Arthroplasty

TKO

To Keep Open

TMJ

Temporomandibular Joint

TMP

Transmembrane Pressure tol

Tolerates or tolerated

T/O

Telephone Order

TP

Total Protein

TPN

Total Parenteral Nutrition

TPR

Temperature, Pulse, Respiration

TR

Tricuspid Regurgitation

TS

Tricuspid Stenosis

TSH

Thyroid Stimulating Hormone tsp

Teaspoon

TUR

Transurethral Resection

TURP

Transurethral Resection of Prostate

Tx

Treatment

U

UA

Urinalysis

UDE

Undetermined Etiology

UFR

Ultrafiltration Rate

UGI

Upper Gastrointestinal Series ung

Ointment

UPC

Units Packed Cells

URI

upper Respiratory Infection

UTI

Urinary Tract Infection

U-Wave

U-Wave of the ECG

V Vag

Vaginal

VAH

Veterans Affairs Hospital

VAMC

Veterans Affairs Medical Center

VCG

Vectorcardiogram

VD

Venereal Disease

VDRL

Venereal Disease Research Laboratory

Vent

Ventricle

VH

Visual Hallucinations vit

Vitamin(s)

V/0

Verbal Order

V.P.

Venous Pressure

V.P. shunt

Ventricular Peritoneal shunt

V.S.

Vital Signs

W

WBC

White Blood Count w.b.c.

White blood cell

W/C

Wheelchair wk

Week

WFL

Within Functional Limit

WNL

Within Normal Limits

W/0

Without

WPWS

Wolff-Parkinson-White Syndrome wt

Weight

X

XRT

Radiation or X-Ray Treatment

X-Ray

Roentgen Rays

SYMBOLS

Approximately

Change

Decrease

Increase

Minus

Plus

Secondary

Hours (like 4()

5FU

Fluorouracil

Plus or minus; indefinite

Female or

Male