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