Medical Records Management



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carcinoma-in-situ

CIS

cardiopulmonary resuscitation

CPR

cardiovascular disease

CV, CVD, CD

cardiovascular heart disease

CHD

cardiovascular system

CVS

Carnitine acylcarnitine translocase deficiency

CACT

Carnitine palmitoyl II deficiency

CPT-II

Carnitine Uptake Defect

CUD

case unknown

CU

Casual Blood Sugar

CBS

catheter

cath

caucasian

cauc

cavity

cav

centigrade

cent

Centigrade/Celsius

C

centigram

cg, Cgm

central nervous system

CNS

cephalopelvic disproportion

CPD

Cerebral Palsy

CP

Cerebral Spinal Fluid

CSF

Cerebrovascular Accident

CVA

Certificate of Need

CON

Certified Medical Assistant

CMA

Certified Nurse Midwife

CNM

certified, certificate

cert, crt

cervical

cerv, C

Cervical Intraepithelial Neoplasm

CIN

cervical motion tenderness

cmt

cervical spine

C-spine

cervix

cerv, Cx

Cesarean Delivery

CD

Cesarean Section

CS, C-section

chemical, chemistry

chem

chest

ch

chest pain

CP

chest x-ray

CXR

chest-back

C-B

chicken pox

ch px

chief complaint

C.C., CC

child

ch

Child Advocacy Centers

CAC

child fatality review

CFR

Childhood Lead Poisoning Prevention Program Nurse

CLPPP

Chlamydia Trachomatis/Neisseria Gonorrhea

CT/GC

Chlamydia Test

CT

chlorine

Cl

cholesterol

CH, chol

cholesterol/triglyceride ratio

C/TG

Chorionic Gonadotropin

CG

chromium

Cr

chronic

chr

chronic liver disease

CLD

chronic obstructive pulmonary disease

COPD

chronic serous otitis media

CSOM

chronic tuberculosis

CTB

circulate, circumference

circ

circumcision

circ, circum

Citrullinemia type I

CIT-I

Citrullinemia type II

CIT-II

clear to auscultation

CTA

clear to auscultation bilaterally

CTA(B)

clinic, clinical

clin

Clinical Assessment Software Application

CASA

clinical breast exam

CBE

Clinical Laboratory Improvement Act

CLIA

Clinical Nurse Specialist

CNS

clue cells

CC

coagulation

coag

cold knife conization

CKC

combined oral contraceptives (estrogen & progestin)

COCs

communicable disease

commun dis, CD

Community Health Nurse

CHN

compare, compound

comp

complains of

C/O, ℅

complete

compl

complete blood count

CBC

complication

complic

compound

compd

Compressions-Airway-Breathing

CAB

computer-aided detection

CAD

computerized axial tomography

CAT scan

concentrated, concentration

conc

condition

cond

confirmed & compatible

C&C

congenital

cong

Congenital Adrenal Hyperplasia

CAH

congenital heart disease

CHD

Congenital Hypothyroidism

CH

Congenital Polycystic Disease

CPD

Congenital Rubella Syndrome

CRS

congestive heart failure

CHF

conjugated

conjug

Consistent with

C/w

constant

const

contact

C

Continue with

C/W

continuing education

CE

continuing education unit

CEU

Contraceptive Technology


CT

Contraction Stress Test

CST

contractions

contrx

control

ctr

copper

Cu

coronary care unit

CCU

correct, correction

corr

counterclockwise

CCW

cryosurgery, cryotherapy

cryo

cubic micron

CU

culture

cult

Culture Filtrate Protein-10

CFP-10

culture & sensitivity

C&S

current

cur

current diagnosis

cd

current procedural terminology

CPT-4

cutting in to

-otomy

Cystic Fibrosis

CF

cystoscopy

cysto

Cytomegalovirus

CMV

D

date of admission

D/A

date of birth

D/B, DOB

date of death

DOD

date of service

DOS

date

D

daughter

dau

decameter

dkm

deceased

Dec, dec’d

deceleration

decel

decibal

dB

decigram

dg, dgm

deciliter

dL

decimeter

dm

decrease, decreased

decr

deep tendon reflex

DTR

deep vein thrombosis

DVT

deficiency

def

deformity

deform

degeneration

degen

degree

Deg, deg

delayed-type hypersensitivity

DTH

delivery, delivered

del

Denver Articulation Screening Examination

DASE

Denver Development Screening Tool

DDST

Deoxyribonucleic Acid

DNA

Department for Community Based Services

DCBS

Department for Public Health

DPH

dependent

dep

Depot-medroxyprogesterone acetate

DMPA

derive, derivative

deriv

descent, descending

desc

development

Dev, devel

developmental age

DA

developmental disability

DD

developmental quotient

DQ

Devereux Early Childhood Assessment

DECA

deviated nasal septum

DNS

diabetes

diab

Diabetes Centers of Excellence

DCOE

Diabetes Mellitus

DM

Diabetes Self Management Training

DSMT

Diabetic Ketoacidosis

DKA

diagnosis

Dx, diag

diagram

diagm

diameter

diam

diarrhea and vomiting

D & V

diastolic blood pressure

DBP

did not keep appointment

DNKA

diet as tolerated

DAT

dietary reference intakes

DRI

Diethylstilbestrol

DES

differential blood count

dif

dilation and curettage

D & C

dilation and evacuation

D & E

diminish, dimension

dim

Diphtheria

diph

direct, direction, director

dir

direct fluorescent antibody

DFA

directly observed preventative therapy

DOPT

directly observed therapy

DOT

disabled

dis

discharge

disch, D/C, DC, dc

discontinue

disc, D/C, d/c

Discussed with

D/W

disease

dis

Disease Intervention Specialist

DIS

dislocate, dislocation

disloc

dispense

disp

disseminated

dissem

Disseminated Gonococcal Infection

DGI

dissolved

dissd

distal

D

distal pulses

DP

distance

dis

distribute, disturbance

dist

divide, division

div

Division of Administration & Financial Management

AFM

Division of Laboratory Services

DLS

Division of Maternal & Child Health

MCH

Division of Prevention & Quality Improvement

PQI

Doctor’s orders

DO

domestic violence

DV

domestic violence/sexual assault

DV/SA

dominant

dom

Dorsalis pedis pulse

DP

dose, dosage

D,dos

double vision

dv

Down’s Syndrome

DS

dram

dr

dressing

Drsg, dsg

drink

bib

driving under influence

DUI

drop by drop

guttat

drops

gtt

drug history

D/H

drug of choice

DOC

dry dressing

DD

duck embryo vaccine

DEV

Ductal Carcinoma in situ – type of breast cancer

DCIS

duplication, duplicate

dup

durable medical equipment

DME

dysfunctional uterine bleeding

DUB

E

each eye

OU

ear, nose, (and) throat

ENT

early periodic screening diagnosis and treatment

EPSDT

ears, eyes, nose, throat

EENT

ectopic pregnancy

EP

educate, education

educ

effect, effective

eff

effective dose

ED

egg, ovary

ov

elbow

elb

elect, elective

el, elect

elective termination of pregnancy

ETP

electrocardiogram

ECG, EKG

electroencephalogram

EEG

Electronic Disease Notification

EDN

electronic fetal monitor

EFM

elevated blood lead level

EBLL

eligible

elig.

embryo

Emb

emergency

emer

emergency contraception

EC

emergency contraceptive pills

ECP

emergency operations plan

EOP

emergency room

ER

emotional

emot

EndoCervical Curretage

ECC

Endometrial Biopsy

EMB

enhanced-potency Inactivated Poliovirus Vaccine

eIPV

enlarged

enl

environment

environ

Environmental Smoke Exposure

ETS

Enzyme Immunoassay

EIA

Enzyme-linked Immunoadsorbent Assay

ELISA

eosinophil

eos

epidemiology

epi

episiotomy

epis

epithelial

EPITH

Epstein-Barr Virus

EBV

equal

eq

equal bilateral breath sounds

EBBS

equipment

equip

equivalent

equiv

erectile dysfunction

ED

erythrocytes per deciliters

ery/dL

Erythromycin

EES

Escherichia coli

E coli

essential

ess

estimated blood loss

EBL

estimated date of confinement

EDC

estimated fetal weight

EFW

estimated gestational age

EGA

estradiol

E2

estrogen

E, ESG

estrogen replacement therapy

ERT

Ethanol or Ethyl alcohol

EtOH, EOH

Ethinyl estradiol

EE

Ethmbutol

EMB

evacuate, evacuation

evac

evaluate and advise

E&A

every 2 hours

q2h

every 3 hours

q3h

every 4 hours

q4h

every 5 hours

q5h

every 8 hours

q8h

every day

qd

every four hours

qqh

every hour, each hour

qh

every morning

qam, qm

every night

qn, qpm

every other day

qod

every other hour

qoh

every other night

qon

examination

Ex, exam

except, excision

exc

Expanded Role Registered Nurse

ERRN

expected date of delivery

EDD

expected, expired

exp

expire, expiration

expir

expressed breast milk

EBM

exterior, external

ext

extremity

ext

eye

E

F

face-to-face

En face

failure to thrive

FTT

family

fam

family support worker

FSW

Family Educational Rights and Privacy Act

FERPA

family goal sheet

FGS

family history

F/H, FH, FHx

family nurse practitioner

FNP

family planning

FP

family planning education materials

FPEM

family resource youth services center

FRYSC

fasting blood glucose

FBG

fasting blood sugar

FBS

fasting lipid panel

FLP

fasting plasma glucose

FPG

fat free

FF

father

F

fecal occult blood test

FOBT

Federal Trade Commission

FTC

feeding

fdg

fee-for-service

FFS

female

Fe

female genital tract

FGT

fertility awareness methods

FAM

fetal alcohol syndrome

FAS

fetal heart rate

FHR

fetal heart sounds

FHS

fetal heart tones

FHT

fetal movements

FM

fever of unknown origin

FUO

fibrocystic breast

FCB

Fibromyalgia Syndrome

FMS

fine needle aspiration (cytology)

FNA(c)

finger stick blood glucose/sugar

FSBG or FSBS

first menstrual period

FMP

flexion

flex

fluid

Fl, fld

fluorescent treponemal antibody absorption test

FTA-ABS

Fluoroquinolone

FQN

foam and condoms

F&C

folic acid

FA, B9

follicle-stimulating hormone

FSH

force fluids

ff

follow-up

F/U, FU

follow-up nutrition education by kiosk

FNEK

follow-up nutrition education per protocols

(wic abbreviation)



FNEPP

foot, feet

ft

for further appointment

FFA

for your information

FYI

forearm

FA

four times a day

qid

fracture

frac, fx

fragment

frag

from

fr

full mouth series

FMS

full range of motion

FROM

full strength

FS

full term

FT

full term normal delivery

FTND

function

func

fungal elements

FE

G

Galactosemia

GAL

gallbladder

GB

Gamma Globulin

GG

Gastroesophageal Reflux

GER

Gastroesophageal Reflux Disease

GERD

gastrointestinal

GI

genitourinary

GU

genitourinary system

GUS

gestational diabetes mellitus

GDM

gland

gl

Glaxo Smith Kline

GSK

glomerular filtration rate

GFR

glucose

glu

glucose challenge test

GCT

glucose insulin tolerance test

GITT

glucose tolerance test

GT, GTT

Glutaric academia type II

GA-II

gluteus maximus

glut max

gold

Au

Gonadotropin-releasing hormone

GnRH

Gonococcal Isolate Surveillance Project

GISP

Gonococcal Urethritis

GU

gonococcus/gonorrhea

gc, GC

government

govt

gradual, gradually

grad

grain

gr

gram

g, gm

gram negative

GN

gram negative bacillus

GNB

gram negative cocci

GNC

gram negative diplococci

GND

gram per deciliter

g/dL

gram positive

GP

gram positive cocci

GPC

grandfather

GF

grandmother

GM

Gravida

G

gravity

grav

Group A streptococcus

GAS

Group B beta-hemolytic streptococcus

GBBS

Group B streptococcus

GBS

Growing Great Families

GGF

Growing Great Kids

GGK

growth hormone

GH

guide, guidance

guid

Guillain-Barré Syndrome

GBS

gynecologist, gynecology

Gyn, GYN
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