Table Of ContentProcedure
Procedure on Approved Abbreviations for Use in the Health
Care Record
Date Created: 7June 2010
Last Updated: 7June2010
Version 1.0
Copyright SWAHS Page 1 of 84
Procedure on Approved Abbreviations for Use in the Health Care Record
Date Created:
Last Updated: 7 June 2010
Sydney West Area Health Service
Table of Contents
Symbols ............................................................................................................................... 5
General Abbreviations ......................................................................................................... 7
Abbreviations for Prescribing and Administering Medicines .............................................. 63
Nutrition Related Abbreviations ......................................................................................... 67
Therapy Related Abbreviations ......................................................................................... 69
Service/Role Related Abbreviations .................................................................................. 78
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
Purpose
It is a requirement of NSW health policy1 and the SWAHS Procedure on Clinical Documentation in
the Health Care Record that only abbreviations and symbols approved for use by SWAHS are
used to document in the health care record.
The purpose of this procedure is to
To mandate a standard set of abbreviations that are permitted to be used in clinical
documentation in SWAHS.
To provide a standard level of documentation in SWAHS that is consistent across discipline
and facility.
This procedure is intended to be read in conjunction with the SWAHS Procedure on Clinical
Documentationin the Health Care Record.
Scope
This procedure applies to all clinical, nursing, allied and other staff who are required to document in
the patient/client health care record – whether it isin electronic or paper-based format.
It applies across all inpatient, outpatient and community health settings.
Note: The abbreviations contained within this proceduremust not to be used on Death Certificates.
Definitions
For the purposes of this procedure, the following key definitions and acronyms apply.
In this document, the term:
Must – indicates a mandatory action required by a NSW Health policy directive, law or
industrial instrument.
Should – indicates an action that is to be followed unless there is justifiable reasons for taking
a different course of action.
May – a suggested course of action that might assist in compliance with recordkeeping
dependent on local requirements.
Electronic Records
Records created, communicated and maintained by means of electronic equipment2
Health Care Record
A type of corporate record that is a documented account of a patient/client’s health, illness and/ or
treatment during each visit or stay at a hospital, nursing home, PC&CH centre or related area
health care facility in a hard copy or electronic form.
The record is used to care for the patient/client during an episode of care but may also be used for
future episodes of care, communication with external health providers and regulatory bodies,
planning, research, education, financial reimbursement, quality improvement and public health.
1 NSW Health PD2005_127 – Records, Principles for Creation, Management, Storage and Disposal of Health Care Records, 25 January
2005, page 7
2
Cited by State Records Authority of NSW, Standard on Full and Accurate Records, p.11, as a reference taken fromAustralian Standard
AS ISO 15489 Part 1 Clause 3.10
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
The health care record may also become an important piece of evidence in protecting the legal
interests of the patient/client, clinician or health service.
The health care record may be in hard copy, electronic or both. The provisions of this procedure
apply equally to both paper based and electronic medical records. Where a health care record
exists in both paper and electronic form this is known as a hybrid record. For further information
about the hybrid medical record refer to SWAHS Hybrid Medical Record Policy.
Patient/Client
Any person who receives services from health care facilities in NSW. Either term may be chosen
for use, depending on the context of health care provision. For the purposes of this standard, the
term patient/client is used.
Procedure
1 Approved Abbreviations and Symbols
On the following pages is a list of a standard set of abbreviations that are permitted to be used in
clinical documentation in the health care record.
For ease of reference these abbreviations have been separated into the following categories
Symbols
General abbreviations
Medication/drug related abbreviations
Therapy related abbreviations
Service/role related abbreviations.
Note:
Where there is more than one of the same abbreviation in this approved list, health care context
will indicate which abbreviation is appropriate for use. Where more than one of the same
abbreviation exists and the health care context does not assist in determining appropriate use, the
abbreviation has not been included in this procedure as an approved abbreviation and is required
to be written in full.
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
Symbols
Abbreviation/ Symbol Meaning/ Explanation
@ At
& And
Increased or Up
Decreased or Down
Transverse Right (physio)
Transverse Left (physio)
= Equals
≠ Is not equal to
# Fracture
approximately
≈
♂ Male
♀ Female
+ve Positive
-ve Negative
∆ Diagnosis
Ψ Psychiatric
With
/60 Indicating minutes
/7 Indicating days
/12 Indicating Months
/24 Indicating hours
/40 Indicating gestation in weeks
/52 Indicating weeks
1/365 Daily/ Day
10 First degree, primary
20 Second degree, secondary
30 Third Degree, tertiary
+ Slight Trace
++ Trace
+++ Moderate trace
++++ Large Trace
- Absent
® or ® or R Right
(L) or L or L Left
< Less than
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
Symbols
Abbreviation/ Symbol Meaning/ Explanation
> More than
Without
Therefore
° (superscript) No, no history of
% Percent
? Doubtful, questionable, query
Degrees Celsius
˚c
w/in or c’/ in Within
α1- ATD Alpha1- antitrypsin deficiency
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
General Abbreviations
Abbreviation/ Symbol Meaning/ Explanation
A
A/ Assessment
a/a As above
AA Alcoholics Anonymous
A1, A2 Aortic Valve, 1st sound, 2nd sound
AAA Abdominal Aortic Aneurysm
AAL Anterior – Axillary Line
AB Apex Beat
Ab Antibody
Abdo Abdominal
ABG/s Arterial Blood Gas(es)
ABI Acquired Brain Injury/Impairment
ABS Acute Brain Syndrome
AC Acromioclavicular (joint)
ACA Anterior Cerebral Artery
ACC Acute Care Certificate
ACL Anterior Cruciate Ligament
ACM Ambulatory Cardiac Monitoring
ACS Acute Coronary Syndrome
ADC AIDS Dementia Complex
ADD Attention Deficit Disorder
ADH Antidiuretic Hormone
ad lib Ad Libitum; as desired
Add Adduction
ADHD Attention Deficit Hyperactivity Disorder
ADL Activities of Daily Living
Adm Admission/Admitted
ADR Adverse Drug Reaction
ADRAC Adverse Drug Reactions Advisory Committee
AE Air Entry
AEA Above Elbow Amputation
AEB Atrial Ectopic Beat
A/F or AF Artificially Feeding
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
General Abbreviations
Abbreviation/ Symbol Meaning/ Explanation
AF Atrial Fibrillation/ Flutter
AF Activity Factor
AFB Acid Fast Bacilli
AFLP Acute Fatty Liver of Pregnancy
AFO Ankle Foot Orthosis
AFP Alpha Fetoproteins
Ag Antigen
AGN Acute Glomerulonephritis
AH Abdominal Hysterectomy
AHD Arteriosclerotic/Atherosclerotic Heart Disease
AHF Anti- Haemophiliac (Factor VIII)
AI Aortic Incompetence
AICD Automatic Implantable Cardiac Defibrillator
AIDS Acquired Immune Deficiency Syndrome
AIH Autoimmune Hepatitis
AIVR Accelerated Idioventricular Rhythm
AJ Ankle Jerk
AKA Above Knee Amputation/Also Known As
ALA Assisted Local Anaesthetic
Alb Albumin
ALD Alcoholic Liver Disease
ALF Acute Liver Failure
ALG Anti- Lymphocytic Globulin
ALL Acute Lymphoblastic/Lymphocytic/Lymphoid Leukaemia
ALP (Alkphos) Alkaline Phosphotase
ALS Amyotrophic Lateral Sclerosis
ALT Alanine–Amino Transferase
Alt Sl (ALT SL) Alternate Side Lying
am/a.m Morning
AMA Anti-mitochondrial Antibody
AMD Age related Macular Degeneration
AMI Acute Myocardial Infarct
AML Acute Myeloid Leukaemia
AMP Austin Moore Prothesis
Amp Ampere
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
General Abbreviations
Abbreviation/ Symbol Meaning/ Explanation
AMRI Anteromedial Rotary Instability
AN Antenatal
Anaes Anaesthetic
ANA Antinuclear Antibody
ANCA Anti-Neutrophil Cytoplasmic Antibodies
Angio Angiocardiography
ANLL Acute Non-Lymphocytic Leukaemia
ANS Autonomic Nervous System
Ant Anterior
Anti- LKM Ab Anti-Liver/ Kidney Microsomal Antibody
AODM Adult Onset Diabetes Mellitus
AP Antero-Posterior
APC Activated Protein C
APC Argon Plasma Coagulation
APC Adenomatous Polyposis Coli
APH Antepartum Haemorrhage
APL Abductor Pollicis Longus
APO Acute Pulmonary Oedema
Appt. Appointment
APR Abdomino Perineal Resection
APTT Activated Partial Thromboplastin Time
ARBD Alcohol Related Brain Damage
ARC AIDS Related Complex
ARDS Adult Respiratory Distress Syndrome
ARF Acute Renal Failure
ARM Artificial Rupture of Membranes
AROM ActiveRange of Movement
ARV AIDS Related Virus
AS Aortic Stenosis
ASAP As Soon As Possible
ASCA Anti-Saccharomyces Cerecisiae Antibody
ASCVD Arteriosclerotic Cardiovascular Disease
ASD Atrial Septal Defect
ASHD Arteriosclerotic Heart Disease
ASIS Anterior Superior Iliac Spine
ASLR Active Straight Leg Raise
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Sydney West Area Health Service
General Abbreviations
Abbreviation/ Symbol Meaning/ Explanation
ASO Arteriosclerotic Obliterans
AST Aspartate Amino Transferase
ASVD Arteriosclerotic Vascular Disease
AT Atrial Tachycardia
ATN Acute Tubular Necrosis
ATNR Asymmetrical Tonic Neck Reflex
ATOR At Time Of Report
ATS Antitetanus Serum
ATSP Asked to See Patient
Ausc. Auscultation
AV Atrioventricular
AV Arteriovenous
AV Aortic Valve
AVB Atrioventricular Block
AVF Arteriovenous Fistula
AVF Acute Ventricular Failure
AVM Arteriovenous Malformation
AVMs Arteriovenous Malformations
AVN Atrioventricular Node
AVN Avascular Necrosis
AVO Apprehended Violence Order
AVR Aortic Valve Replacement
AVNRT Atrioventricular Nodal Re-entrant Tachycardia
A&W Alive and Well
A/W Associated With
AWL/AWOL Absent Without Leave
AWS Alcohol Withdrawal Syndrome
Ax Assessment
AXR Abdominal X- ray
AZ Aschheim- Zondek test (for Pregnancy)
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Procedure on Approved Abbreviations for use in the Health Care Record
Date Created: 7 June 2010
Last Updated: 7 June 2010
Description:the Health Care Record that only abbreviations and symbols approved for use by SWAHS are . Automatic Implantable Cardiac Defibrillator. AIDS .. Exploration Common Bile Duct. ECCE. Extra Capsular Cataract Extraction.