Document 140661
MCCMH MCO Policy 2-017 ABBREVIATIONS, ACRONYMS AND SYMBOLS APPROVED FOR RECORD USE Date: 6/1/11 (demographics, etc.), information required by the Michigan Mental Health Code or other provision of law, and information required by MCCMH MCO policies. V. VI. Standards A. Only MCCMH approved abbreviations, acronyms and symbols (Exhibit A) are to be used in documentation generated by MCCMH network providers for inclusion in clinical records of MCCMH consumers. B. Each abbreviation, acronym and symbol may be used only to signify the meaning indicated for it in this policy. C. Standard recognized abbreviations for time, days of the week, months of the year; measurements of weight, length, amount and chemical symbols may be used. D. Unauthorized abbreviations may be used only after the complete work or phrase is used at least once in the text followed by the abbreviation in parentheses. The abbreviation may be used throughout the text for that document only. If the abbreviation is used in another document, the procedures previously described must be followed [e.g. single white male (SWM)]. E. Abbreviations, acronyms and symbols that are included in the “DO NOT USE” chart (Exhibit B) are not acceptable and may not be used in any written material in the clinical record. F. In the event that a physician’s order contains an unauthorized abbreviation, acronym or symbol, nurses and pharmacists and others reading the order must exercise discretion to determine if the order is rendered unclear and, in such cases, must contact the ordering physician for clarification. G. For documents which are most frequently released to non-network providers (e.g. intakes, psychosocial assessments, closing summaries, etc.) abbreviations which are idiosyncratic to MCCMH must be spelled out, particularly the names of provider agencies. Consideration must be given to ensuring that the document is understandable to non-network readers. H. The use of any abbreviation, acronym, or symbol is discouraged in instructions, prescriptions, handouts or any other written materials provided to consumers and their families. Procedures A. None. Page 2 of 12 MCCMH MCO Policy 2-017 ABBREVIATIONS, ACRONYMS AND SYMBOLS APPROVED FOR RECORD USE Date: 6/1/11 VII. VIII. References / Legal Authority A. Joint Commission on Accreditation of Healthcare Organizations (JCAHO), FAQs for the 2006 National Patient Safety Goals (Updated 12/08) B. Stedman’s Abbreviation, Acronyms & Symbols, CD-Rom (3Rev Ed) Exhibits A. Abbreviations, Acronyms, and Symbols for Charting B. Do Not Use List Page 3 of 12 Macomb County Community Mental Health Abbreviations, Acronyms, and Symbols for Charting The following abbreviations, acronyms and symbols may be used in any written material which is to be included in a MCCMH clinical record: A. General Terms Abbreviation / Acronym a A.A. AA A&B ABE a.c. A.C.S.W. a.d. A.D.A. ADD ADHD A.D.L.S. Ad lib Adm. AEB AFC AIDS AIMS a.k.a. A.M.A. a.m. amp. amt ante apt appt AROM a.s. as tol ATO AWOL B.A. B b/c b.i.d. B.M. B/P B.S. BSN Translation Before Alcoholics Anonymous Associate in Arts Assault and battery Adult Basic Education Before meals Academy of Certified Social Workers Right ear American Dietetic Association Attention Deficit Disorder Attention Deficit Hyperactivity Disorder Activity of daily living skills As much as needed (as desired) Admission/Admitted As evidenced by Adult Foster Care Acquired Immune Deficiency Syndrome Abnormal Involuntary Movement Scale Also known as Against medical advice Before noon Ampule Amount Before Apartment Appointment Active range of motion Left ear As tolerated Alternative Treatment Order Absent without leave Bachelor of Arts Bilaterally Because Twice daily Bowel movement Blood pressure Bachelor of Science Bachelor of Science – Nursing MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 4 of 12 Abbreviation / Acronym BTP BTPRC c CA cal cap CBC CC CCISC CCW CII CHI chol cl CLF CLS cl. psych. cmi cms CNS C/O cons. cont. COPD CP CVA dc D/C DD Detox. DO DOA DOB Dr. DSM-IV DTs DWI DUI Dx EBP ECT EEG e.g. EI EKG EMG EMI Translation Behavior Treatment Plan Behavior Treatment Plan Review Committee With Cancer Calorie Capsule Complete blood count Chief complaint Continuous Comprehensive Integrated Systems of Care Carrying concealed weapon Community Inclusion and Integration Closed head injury Cholesterol Client Community Living Facility Community Living Supports Clinical psychology, clinical psychologist Chronically mentally ill Client services manager, client services management Central nervous system Complains of or complaints offered Consultation Continue, continued, continuing Chronic Obstructive Pulmonary Disease Cerebral Palsy Cerebral vascular accident discontinue Discharge Developmentally disabled Detoxification Doctor of Osteopathy Dead on arrival Date of birth Doctor Diagnostic and Statistical Manual of Mental Disorders – 4th Ed. Delirium tremens Driving while intoxicated Driving under the influence Diagnosis Evidence Based Practice Electroconvulsive therapy Electroencephalogram For example Emotionally impaired Electrocardiogram Electromyogram Educable Mentally Impaired MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 5 of 12 Abbreviation / Acronym ENT EPS ER Etc. ETOH ETS Eval. Exam FBS FSIQ Fam. FI F/U Fx GAF G.E.D. G.I. Gyn Hct. Hgb. HI HIPAA HIV Hosp. Hrs. h. s. Ht. HTN Hx i.e. IEP IEPC IF IM Imp. Inj IPOS IQ IUD IV L Lab LBSW LD Li2CO3 LLP LLPC LP Translation Ear, Nose and Throat Extra Pyramidal Symptoms Emergency room And others (et. Cetera) Ethanol/alcohol Emergency Telephone Service Evaluate Examination Fasting blood sugar Full Scale Intelligence Quotient Family Fiscal Intermediary Follow up fracture Global Assessment of Functioning Scale General Equivalency Diploma Gastrointestinal Gynecology, gynecological Hematocrit Hemoglobin Homicidal ideations Health Insurance Portability and Accountability Act Human immunodeficiency virus Hospital, hospitalized, hospitalization Hours Hour of sleep (bedtime) height Hypertension History For example Individual Educational Plan Individual Educational Planning Committee Independent Facilitation intramuscular Impression Injection Individual Plan of Service Intelligence quotient Intrauterine Device Intravenous Left Laboratory Licensed Bachelor of Social Work Learning disability Lithium carbonate Limited Licensed Psychologist Limited Licensed Professional Counselor Licensed Psychologist MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 6 of 12 Abbreviation / Acronym LMP LMSW LOA LOC LOF LOS LPN M.A MAOI MD Med.(s.) Mg. MI Min. ml. mm. MR Mo. M.S. M.S.E.d MSE N.A. N/A Neuro Nka NGPD NPO OB OD o.d. o.s. O.И OT OTC Oz. P p.c. PE PEARL Per Ph.D. PHI PIQ p.m. P.M.H. p.o. PRC Prn Translation Last menstrual period Licensed Master of Social Work Leave of absence Level of Care Level of functioning Length of stay Licensed Practical Nurse Master of Arts Monoamine Oxidase Inhibitor Medical Doctor medication milligram Mentally ill, mental illness Minute Milliliter Millimeter Mentally retarded, mental retardation Month Master of Science Master of Science - Education Mental status evaluation Narcotics Anonymous Not applicable Neurological No known allergies No grandiose or persecutory delusions Nothing by mouth Obstetrics, obstetrical Overdose Right eye Left eye Both eyes Occupational Therapy Over the counter Ounce After After meals Physical examination Pupils equal and reactive to light Through Doctor of Philosophy Protected Health Information Performance Intelligence Quotient After noon Past medical history Orally/by mouth Placement Review Committee Whenever necessary (as needed) MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 7 of 12 Abbreviation / Acronym PSS Psych P.T. Pt PTSD Prog. q qAM qh qhs QI q.i.d. Q.R. R Re Rec. Ref. Rehab. RN Ret’d RSST R/O ROM R.T. RTC Rx s SA S/E SED SEI SI/HI SI SMI SOB SPMI SSD SSI Stat STD STEP SUD sx Tab. t.b.a. T.B.D. TD Translation Peer Support Specialist Psychiatry, Psychiatrist, psychiatric Physical Therapy Patient Post traumatic stress disorder Prognosis Every Every morning Every hour Every night Quality Improvement Four times daily Quiet room Right Regarding, with regard to (about) Recommendation, recommend Ref, referral Rehabilitation Registered Nurse Returned Registered Social Service Technician Rule out Range of motion Recreational Therapy Return to clinic Prescription, prescribe Without Substance Abuse Side effects Severe Emotional Disturbance (Children and Adolescents) Severely Emotionally Impaired Suicidal Ideation/Homicidal Ideation Suicidal Ideation Seriously Mentally Ill Shortness of breath Severely and Persistently Mentally Ill Social Security Disability Supplemental Security Income Immediately Sexually Transmitted Disease Services To Enhance Potential Substance Use Disorder Symptoms Tablet To be arranged To be determined Tardive Dyskinesia MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 8 of 12 Abbreviation / Acronym TDD TI t.i.d. TLC T.O. TPR tx UA unk. ULA V.D. VIQ v.o. v.s. W/B WBC W/C W/D WFL w/i WNL w/o W/S Wt. X y/o yr. B. Translation Telecommunication device for the deaf Telephone inquiry Three times daily Tender loving care Telephone Order Temperature, pulse, respiration Treatment, therapy Urinalysis Unknown Unauthorized leave of absence Venereal Disease Verbal Intelligence Quotient Verbal order Vital signs Weight bearing White blood cell count Wheelchair Withdrawal Within functional limits Within Within normal limits Without Workshop Weight Times Year old Year Standardized Medication Administration Schedule Abbreviation Once daily qhs / Pediatrics qhs / Adults q4 hrs q6 hrs q8 hrs BID/ q12 hrs BID (ac) BID (pc) BID w/ meals TID TID (ac) TID (pc) TID w/ meals TID Respiratory Care QID Time 8:30 AM 0830PM 0930PM 1230AM-0430AM-0830AM-1230PM-0430PM-0830PM 1230AM-0630AM-1230PM-0630PM 1230AM-0830AM-0430PM 0830AM-0830PM 0730AM-0530PM Before Meals 0830AM-0630PM After Meals 0800AM-0600PM 0830AM-1230PM-0430PM 0730AM-1130AM-0530PM Before Meals 0830AM-1230PM-0630PM After Meals 0800AM-1200Noon-0600PM 0800AM-1400PM-0800PM 0830AM-1230PM-0430PM-0830PM MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 9 of 12 C. Symbols Symbol # I II III ♀ ♂ ᇞ ↑ ↓ → - + 1:1 2° D. Translation number One Two Three Female Male Change Increase Decrease Leading to Negative Positive One to one Secondary to Psychological Tests Abbreviation / Acronym ACL BG BPRS CAFAS CAT CPI CRS-P/T DAP HTP IQ JAS KFD MBTI MMPI-R PIAT PIC Psych. Eval. P.E. ROR SDMT 16PF SS TAT WAIS-R WISC-R WPPSI WRAT-R Translation Adjective Check List Bender Gestalt Brief Psychiatric Rating Scale Child and Adolescent Function Assessment Scale Children’s Apperception Test California Psychological Inventory Connor Rating Score – Parent / Teacher Draw a Person House Tree Person Intelligence Quotient Jenkins Activity Survey Kinetic Family Drawing Myers-Briggs Type Indicator Minnesota Multiphasic Personality Inventory-Revised Peabody Individual Achievement Test Personality Inventory for Children Psychiatric evaluation Psychiatric evaluation Rorschach Symbol Digit Modalities Test Sixteen Personality Factor Questionnaire Standard Score, Scale Score Thematic Apperception Test Wechsler Adult Intelligence Scale – Revised Wechsler Intelligence Scale for Children – Revised Wechsler Preschool and Primary Scale of Intelligence Wide Range Achievement Test – Revised MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 10 of 12 E. Provider / Program / Department Names Abbreviation / Acronym ACT ALS AOT APS ARC, Inc. BTPRC CCMS CMH CPS DCH DHS DOC EPS First N First SE First SW HFM-East HMO ICSP ISD IMH ITP IOP KH MCCC MCCMH MCOSA MO MOC MORC, Inc. MDCH MRS ORR PIHP PHP QHP SEA SEP SRI SSA VA WRPH Translation Assertive Community Treatment Adult Learning Systems Assisted Outpatient Treatment Adult Protective Services ARC Services of Macomb, Inc. Behavior Treatment Plan Review Committee Community Case Management Services Community Mental Health Children’s Protective Services Michigan Department of Community Health Michigan Department of Human Services Michigan Department of Corrections Emergency Psychiatric Services First Resources and Treatment – North First Resources and Treatment – Southeast First Resources and Treatment – Southwest Henry Ford Macomb – East Health Maintenance Organization Intensive Crisis Stabilization Program Intermediate School District Infant Mental Health Infant-Toddler Project Intensive Outpatient Program Kalamazoo Hospital Macomb County Crisis Center Macomb County Community Mental Health Macomb County Office of Substance Abuse Medication Only Program Mobile Outreach Clinic Macomb-Oakland Regional Center, Inc. Michigan Department of Community Health Michigan Rehabilitation Services Office of Recipient Rights (Macomb County) Prepaid Inpatient Health Plan Partial Hospital Program Qualified Health Plan Single Entry Assessment Supportive Employment Program Social Resources, Inc. Social Security Administration Veterans’ Administration Walter Reuther Psychiatric Hospital MCCMH Approved Abbreviation, Acronyms and Symbols for Charting, (rev. 5/11), MCCMH MCO Policy 2-017, Exhibit A Page 11 of 12 Do Not Use List* The following abbreviations, acronyms and symbols MAY NOT be used in any written material which is to be included in a MCCMH clinical record: Abbreviation / Acronym / Symbol U (unit) IU (International Unit) Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d, qod (every other day) Trailing zero (X.0 mg)** Lack of leading zero (.X mg) MS Potential Problem Use Instead Mistaken for “0” (zero), the number “4” (four) or “cc” Mistaken for IV (intravenous) or the number 10 (ten) Mistaken for each other Write "unit" Period after the Q mistaken for "I" and the "O" mistaken for "I" Abbreviations for drug names Apothecary units @ cc μg Write "daily" Write "every other day" Write X mg Decimal point is missed Can mean morphine sulfate or magnesium sulfate MSO4 and MgSO4 > (greater than) < (less than) Write "International Unit" Confused for one another Misinterpreted as the number “7” (seven) or the letter “L” Confused for one another Misinterpreted due to similar abbreviations for multiple drugs Unfamiliar to many practitioners Confused with metric units Mistaken for the number “2” (two) Mistaken for U (units) when poorly written Mistaken for mg (milligrams) resulting in one thousand-fold overdose Write 0.X mg Write "morphine sulfate" Write "magnesium sulfate" Write “greater than” Write “less than” Write drug names in full Use metric units Write “at” Write “mL” or "ml" or “milliliters” (“mL” is preferred) Write "mcg" or “micrograms” *Taken from the JCAHO Official “Do Not Use List” (Updated 3/5/09) **Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation. MCCMH Do Not Use List, (rev. 4/10), MCCMH MCO Policy 2-017, Exhibit B Page 12 of 12
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