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Date of Issue :
26/9/2019
Medical Records department
Policy and Procedures Manual Date of Revision:
16/09/2019
Document No :
Issue no : 07
SH/ MR/M/ 01
Amendment no 1:
Revision of the
31. POLICY ON STANDARD ABBREVIATIONS FOR USE IN MEDICAL RECORDS AND

MEDICATION ORDERS
1) Use plain English - avoid jargon
2) Write in full - avoid using abbreviations wherever possible, including Latin abbreviations
3) Use generic drug names
4) Exception may be made for combination products, but only if the trade name adequately identifies
the medication being prescribed. For example, if trade names are used, combination products
containing penicillin (eg Augmentin®, Timentin®) may not be identified as penicillin’s. Exception
may also be made where significant bioavailability issues exist, for example cyclosporine,
amphotericin
5) Write drug names in full.
NEVER abbreviate any drug name Some examples of unacceptable drug name abbreviations are: G-
CSF (use filgrastim or lenograstim or pegfilgrastim), AZT (use zidovudine), 5-FU (use fluorouracil),
DTIC (use dacarbazine), EPO (use epoetin), TAC (use triamcinolone) Exception may be made for
modified release products For slow release, controlled release, continuous release or other modified
release products, the description used in the trade name to denote the release characteristics should
be included with the generic drug name, for example tramadol SR, carbamazepine CR For multi-
drug protocols, prescribe each drug in full and do not use acronyms, for example do not prescribe
chemotherapy as ‘CHOP’. Prescribe each drug separately
6) Do not use chemical names/symbols, for example HCl (hydrochloric acid or hydrochloride) may be
mistaken for KCL (potassium chloride) Do not include the salt of the chemical unless it is clinically
significant, for example mycophenolate mofetil or mycophenolate sodium. Where a salt is part of the
name it should follow the drug name and not precede it
7) Dose
Prepared by: Asst. Mgr. MRD and Reviewed by: Quality Department
Manager IP Operations
Approved by: Medical Director Signature:
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• Use words or Hindu-Arabic numbers, i.e. 1, 2, 3 etc Do not use Roman numerals, i.e. do not
use ii for two, iii for three, v for five etc.
• Use metric units, such as gram or ml, do not use apothecary units, such as minims or drams
• Use a leading zero in front of a decimal point for a dose less than 1, for example use 0.5 not
.5 Do not use trailing zeros, for example use 5 not 5.0
• For oral liquid preparations, express dose in weight as well as volume, for example in the
case of morphine oral solution (5mg/ml) prescribe the dose in mg and confirm the volume in
brackets: eg 10mg (2ml)
• Express dosage frequency unambiguously, for example use ‘three times a week’ not ‘three
times weekly’ as the latter could be confused as ‘every three weeks’
8) Avoid fractions, for example - 1/7 could be interpreted as ‘for one day’, ‘once daily’, ‘for one week’
or ‘once weekly’ - 1/2 could be interpreted as ‘half’ or as ‘one to two’
9) Do not use symbols
10) Avoid acronyms or abbreviations for medical terms and procedure names on orders or prescriptions,
for example avoid EBM meaning ‘expressed breast milk
Acceptable Terms or Abbreviation Intended meaning

Dose frequency or timing
BD /bd Twice a day
Tds Three times a day
Qid four times a day
every 4 hrs, 4 hourly, 4 hrly every 4 hours
once a week once a week and specify the day in full, eg,
once a week on Tuesdays
three times a week three times a week and specify the exact days
in full, eg three times a week on Mondays,
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Wednesdays and Saturdays

SOS when required
Stat Immediately
bol, bolus Bolus, in a large single dose
before food before food
after food after food
with food with food
Discontinue Discontinue
dil. dilute
Route of administration
Epidural Epidural
inhale, inhalation inhale, inhalation
Intraarticular Intraarticular
IM Intramuscular
Intrathecal Intra-thecal
Intranasal intranasal
IV intravenous
Irrigation irrigation
Left left
NEB nebulised
NG naso-gastric
PO oral
PEG percutaneous enteral gastrostomy
PV per vagina
PR per rectum
PICC peripherally inserted central catheter
Right right
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Subcut subcutaneous
Subling sublingual
Topica Topical
Sol solution
Syr syrup
lot. Lotion
Units of Measure and Concentration

G gram(s)
International unit(s) International unit(s)
unit(s) unit(s)
L litre(s)
Mg milligram(s)
mL millilitre(s)
microgram, microg microgram(s)
% percentage
Mmol Millimole
Dose Forms
Cap Capsule
Cream Cream
ear drops ear drops
ear ointment ear ointment
eye drops eye drops
eye ointment eye ointment
Inj Injection
metered dose inhaler, inhaler, MDI metered dose inhaler
Mixture Mixture
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ointment, oint Ointment

Pess Pessary
Powder Powder
Supp Suppository
tablet, tab Tablet
Approved medical abbreviations

A-FIB atrial fibrillation
ABG arterial blood gas

ACLS advanced cardiac life support
ACE Inhibitor Angio-tension – converting Enzyme Inhibitors
AKI Acute Kidney Injury
AFB acid fast bacilli
AIDS acquired immune deficiency syndrome
AMI Acute myocardial infraction
ANA antinuclear antibody
ARDS adult respiratory distress syndrome
ARF Acute renal failure
AV atrio-ventricular
AV fistula Arteriovenous Fistula
AVR aortic valve replacement
BILAT Bilateral
BIH bilateral inguinal herniorraphy
BiPAP Bilevel Positive Airway Pressure
BLS basic life support
BMI body mass index
BP blood pressure
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BPH benign prostatic hypertrophy

BS breath sounds
Brady bradycardia
BUN blood urea nitrogen
BMR basal metabolic rate
C1, C2, C3, etc cervical vertebra #1, #2, #3 etc
C-SECTION caesarean section
C-SPINE cervical spine
C/O complaint of (complains of)
Ca Calcium
CA Cancer
CABG coronary artery bypass graft
CAD coronary artery disease
CATH Catheter
CT scan computerized tomography
CBG capillary blood gas
CEPH Cephalic
CHD congenital heart disease
CHF congestive heart failure
CKD Chronic Kidney Disease
CNS central nervous system
CO2 Carbon dioxide
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CSF cerebrospinal fluid
CT scan computerized axial tomography
CVA cerebrovascular accident (stroke)
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CPAP Continuous Positive Airway Pressure

CRF Chronic renal failure
CRP C-Reactive Protein
C&S culture and sensitivity
CVA cerebrovascular accident
CVC central venous catheter
CVP central venous pressure
CXR chest x-ray
DOA dead on arrival/ admission
Dx Diagnosis
DVT deep vein thrombosis
D&C dilatation and curettage
DIC disseminated intravascular coagulation
DM Diabetes Mellitus
DUB dysfunctional uterine bleeding
ECG Electrocardiogram
EEG electroencephalogram
ET Endotracheal
ETT endotracheal tube
ECHO echocardiogram
E. Coli escherichia coli
ECMO extracorporeal membrane oxygenation
EF ejection fraction
ENDO Endoscopy
ERCP endoscopic retrograde
choledochopancreatography
ESR erythrocyte sedimentation rate
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ENT ears, nose, throat (otorhinolaryngology)

FLEX Flexion
Fx Fracture
FA Folic Acid
F Fahrenheit
FBS fasting blood sugar
FNA fine needle aspiration
G gram(s)
GI Gastrointestinal
GYN gynecology (gynecological)
GCS Glasgow Coma Scale
GDM gestational diabetes mellitus
GE gastroesophageal
GERD Gastroesophageal reflux disease
GFR glomerular filtration rate
GTT glucose tolerance test
HR heart rate (hour)
HTN Hypertension
Hx History
HIV human immune deficiency virus
Hb, Hgb hemoglogin
HBAg hepatitis B antigen
HCG human chorionic gonadotrophin
HCO3 Bicarbonate
HD hemodialysis
HDL High Density Lipoprotein
HF heart failure
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HgbA1c or A1c Glycosylated Hemoglobin

H/O history of
HPV Human Papillomavirus
ICP intracranial pressure
ICU intensive care unit
IABP intraaortic balloon pressure
IBS Irritable bowel syndrome
ICD Internal Cardiac Defibrillator
ICH Intracerebral hemmorhage
IMA internal mammary artery-left/right
INR International Normalized Ratio
I&O intake and output
IUD intrauterine device
IV intravenous
IVH intraventricular hemorrhage
JVD jugular vein distension
K+ potassium
KA ketoacidosis
Kcal kilocalories
KUB kidney, ureters, bladder
L-SPINE lumbar spine
L/S-SPINE lumbar sacral spine
LAT Lateral
LMP last menstrual period
LOC level of consciousness (loss of consciousness)
LBBB left bundle branch block
LDL Low density Lipoprotein
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LVF left ventricular function

LFT liver function test
LIMA left internal mammary artery
LMCA left main coronary artery
L.M.P last menstrual period
LOC level of consciousness
LP lumbar puncture
LSC left subclavian
LV left ventricle/ventricular
LVH left ventricular hypertrophy
lytes electrolytes
MI myocardial infarction (heart attack)
MRI. magnetic resonance imaging
MCH mean corpuscular hemoglobin
MCHC mean corpuscular hemoglobin concentration
MCV mean corpuscular volume
MR mitral regurgitation
MVR mitral valve replacement
Na+ sodium
N/A not applicable
NAD no acute distress
NPO nothing by mouth
NSAID nonsteroidal anti-inflammatory drug
NS normal saline
NSTEMI Non-ST Elevation Myocardial Infarction
NTG Nitroglycerine
NR non reactive
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Document No :
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OB/GYN obstetrics/gynecology
O2 oxygen
O2 sat oxygen saturation
ORIF open reduction, internal fixation
OSA Obstructive Sleep Apnea
P pulse
PALP Palpation
PALS pediatric advanced life support
PCO2 partial pressure of CO2
PCOS Polycystic Ovary Syndrome
PD peritoneal dialysis
PDA postural drainage and percussion
peg Percutaneous Endoscopy Gastrostomy
PFT pulmonary function test
pH logarithm of reciprocal of hydrogen ion
POCT Point of Care Testing
PPH primary pulmonary hypertension
PPT Partial Prothombin Time
PRBC packed red blood cells
PSA Prostrate Specific Antigen
pt Prothombin Time
PTCA percutaneous transluminal coronary
angioplasty
PVR pulmonary vascular resistance
Rx Medicine
RR Respiratory rate
RA. rheumatoid arthritis
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RA right atrium
RBBB right bundle branch block
R.B.C. red blood cells
RCA right coronary artery
Rh Rhesus
RV right ventricle/venticular
S/P status post
SOB shortness of breath
ST sinus tachycardia
SVT supraventricular tachycardia
SpO2 oxygen saturation by pulse oximeter
SA sino-atrial
S1, 2, 3,4 Heart sound 1,2,3,4
SAH subarachnoid hemorrhage
SDH Subdural Hematoma
SEMI subendocardial myocardial infarction
SGOT serum glutamic oxaloaetic transaminase
SGPT serum glutamic pyruvate transaminase
T4 thyroxine
TB tuberculosis
TEE transesophageal echocardiogram
THR total hip replacement
TKR total knee replacement
TMT treadmill test
TPN total parenteral nutrition
TRALI Transfusion Related Acute Lung Injury
TSH thyroid stimulating hormone
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TTP thrombotic thrombocytopenic purpura

TUR transurethral resection
TURP Trans urethral resection of prostate
TVH total vaginal hysterectomy
T-SPINE thoracic spine
TIA transient ischemic attack
URI upper respiratory infection
UTI urinary tract infection
VLDL Very Low Density Lipoprotein
VP Shunt ventricular peritoneal shunt
VF ventricular fibrillation
VT ventricular tachycardia
VSD ventricular septal defect
WBC white blood count
Zn Zinc
+ positive
- negative
? questionable
~ approximately
= equal
↑ upper (increased)
L left
R right
↓ lower (decreased)
1° primary
2° Secondary
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Banned Abbreviations in Medication chart documentation
Intended
Abbreviations Misinterpretation Correction
Meaning
µg Microgram Mistaken as “mg” Use “mcg”
Right ear, left Mistaken as OD, OS, OU (right Use “right ear,” “left
AD, AS, AU
ear, each ear eye, left eye, each eye) ear,” or “each ear”
Right eye, left Mistaken as AD, AS, AU (right Use “right eye,” “left
OD, OS, OU
eye, each eye ear, left ear, each ear) eye,” or “each eye”
BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime”
Cubic
cc Mistaken as “u” (units) Use “mL”
centimeters
Premature discontinuation of
medications if D/C (intended to
mean “discharge”) has been
Discharge or Use “discharge” and
D/C misinterpreted as
discontinue “discontinue”
“discontinued” when followed
by a list of discharge
medications
Mistaken as “IV” or
IJ Injection Use “injection”
“intrajugular”
Use “intranasal” or
IN Intranasal Mistaken as “IM” or “IV”
“NAS”
Use “half-strength”
HS Half-strength Mistaken as bedtime
or “bedtime”
At bedtime, Use “half-strength”

hs Mistaken as half-strength
hours of sleep or “bedtime”
International Mistaken as IV (intravenous) or

IU** Use “units”
unit 10 (ten)
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Intended
Meaning
Mistaken as “right eye” (OD-

oculus dexter), leading to oral
o.d. or OD Once daily Use “daily”
liquid medications administered
in the eye
Mistaken as OD or OS (right or
left eye); drugs meant to be
OJ Orange juice Use "orange juice"
diluted in orange juice may be
given in the eye
By mouth, The “os” can be mistaken as Use “PO,” “by

Per os
orally “left eye” (OS-oculus sinister) mouth,” or “orally”
Mistaken as q.i.d., especially if

the period after the “q” or the
q.d. or QD** Every day Use “daily”
tail of the “q” is misunderstood
as an “i”
Nightly at
qhs Mistaken as “qhr” or every hour Use “nightly”
bedtime
Nightly or at Use “nightly” or “at

qn Mistaken as “qh” (every hour)
bedtime bedtime”
Mistaken as “q.d.” (daily) or

q.o.d. or Every other
“q.i.d. (four times daily) if the Use “every other day”
QOD** day
“o” is poorly written
Mistaken as q.i.d. (four times

q1d Daily Use “daily”
daily)
Every evening Use “daily at 6 PM”

q6PM, etc Mistaken as every 6 hours
at 6 PM or “6 PM daily”
SC mistaken as SL (sublingual);
SQ mistaken as “5 every;” the
Use “subcut” or
SC, SQ, sub q Subcutaneous “q” in “sub q” has been
“subcutaneously”
mistaken as “every” (e.g., a
heparin dose ordered “sub q 2
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Intended
Meaning
hours before surgery”

misunderstood as every 2 hours
before surgery)
Sliding scale Spell out “sliding

ss (insulin) or ½ Mistaken as “55” scale;” use “one-
(apothecary) half” or “½”
Sliding scale Mistaken as selective-serotonin Spell out “sliding

SSRI
regular insulin reuptake inhibitor scale (insulin)”
Sliding scale Mistaken as Strong Solution of Spell out “sliding

SSI
insulin Iodine (Lugol's) scale (insulin)”
i/d One daily Mistaken as “tid” Use “1 daily”
Mistaken as “3 times a day” or

TIW or tiw 3 times a week Use “3 times weekly”
“twice in a week”
Mistaken as the number 0 or 4,

causing a 10-fold overdose or
greater (e.g., 4U seen as “40”
U or u** Unit or 4u seen as “44”); mistaken as Use “unit”
“cc” so dose given in volume
instead of units (e.g., 4u seen as
4cc)
Mistaken as unit dose (e.g.,

diltiazem 125 mg IV infusion
As directed
UD “UD” misinterpreted as Use “as directed”
(“ut dictum”)
meaning to give the entire
infusion as a unit [bolus] dose)
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Dose Designations and Intended

Misinterpretation Correction
Other Information Meaning
Do not use trailing

Trailing zero after Mistaken as 10 mg if
zeros for doses
decimal point (e.g., 1.0 1 mg the decimal point is not
expressed in whole
mg)** seen
numbers
Use zero before a

Mistaken as 5 mg if the
“Naked” decimal point decimal point when the
0.5 mg decimal point is not
(e.g., .5 mg)** dose is less than a
seen
whole unit
The period is
Abbreviations such as
unnecessary and could Use mg, mL, etc.
mg. or mL. with a period
mg mL be mistaken as the without a terminal
following the
number 1 if written period
abbreviation
poorly
Drug name and dose run

together (especially Place adequate space
Inderal 40 mg Mistaken as Inderal
problematic for drug between the drug
Tegretol 300 140 mg Mistaken as
names that end in “l” name, dose, and unit of
mg Tegretol 1300 mg
such as Inderal40 mg; measure
Tegretol300 mg)
The “m” is sometimes

Numerical dose and unit Place adequate space
10 mg 100 mistaken as a zero or
of measure run together between the dose and
mL two zeros, risking a 10-
(e.g., 10mg, 100mL) unit of measure
to 100-fold overdose
Use commas for dosing

100000 has been
Large doses without units at or above 1,000,
100,000 units mistaken as 10,000 or
properly placed commas or use words such as
1,000,000 1,000,000; 1000000
(e.g., 100000 units; 100 "thousand" or 1
units has been mistaken as
1000000 units) "million" to improve
100,000
readability
Drug Name
Intended Meaning Misinterpretation Correction
Abbreviations
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Drug Name
Abbreviations
To avoid confusion, do not abbreviate drug names when communicating medical information.
Examples of drug name abbreviations involved in medication errors include:
Not recognized as
APAP acetaminophen Use complete drug name
acetaminophen
Mistaken as cytarabine
ARA A vidarabine Use complete drug name
(ARA C)
Mistaken as
zidovudine
AZT azathioprine or Use complete drug name
(Retrovir)
aztreonam
Compazine Mistaken as
CPZ Use complete drug name
(prochlorperazine) chlorpromazine
Demerol- Mistaken as diphtheria-

DPT Phenergan- pertussis-tetanus Use complete drug name
Thorazine (vaccine)
Diluted tincture of
opium, or
Mistaken as tincture of
DTO deodorized tincture Use complete drug name
opium
of opium
(Paregoric)
Mistaken as potassium Use complete drug name

hydrochloric acid
HCl chloride (The “H” is unless expressed as a salt
or hydrochloride
misinterpreted as “K”) of a drug
Mistaken as
HCT hydrocortisone Use complete drug name
hydrochlorothiazide
Mistaken as
HCTZ hydrochlorothiazide hydrocortisone (seen as Use complete drug name
HCT250 mg)
Mistaken as morphine
MgSO4** magnesium sulfate Use complete drug name
sulfate
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Drug Name
Abbreviations
Mistaken as
MS, MSO4** morphine sulfate Use complete drug name
magnesium sulfate
Mistaken as
MTX methotrexate Use complete drug name
mitoxantrone
novel/new oral
NoAC No anticoagulant Use complete drug name
anticoagulant
Mistaken as patient
PCA procainamide Use complete drug name
controlled analgesia
Mistaken as
PTU propylthiouracil Use complete drug name
mercaptopurine
Tylenol with Mistaken as

T3 Use complete drug name
codeine No. 3 liothyronine
Mistaken as tetracaine,
TAC triamcinolone Use complete drug name
Adrenalin, cocaine
TNK TNKase Mistaken as “TPA” Use complete drug name
Mistaken as TNKase
tissue plasminogen (tenecteplase), or less
TPA or tPA activator, Activase often as another tissue Use complete drug name
(alteplase) plasminogen activator,
Retavase (retaplase)
Mistaken as morphine
ZnSO4 zinc sulfate Use complete drug name
sulfate
Stemmed Drug
Names
nitroglycerin Mistaken as sodium

“Nitro” drip Use complete drug name
infusion nitroprusside infusion
“Norflox” norfloxacin Mistaken as Norflex Use complete drug name
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Drug Name
Abbreviations
intravenous
“IV Vanc” Mistaken as Invanz Use complete drug name
vancomycin
Symbols Intended Meaning Misinterpretation Correction
Symbol for dram

ʓ Dram Use the metric system
mistaken as “3”
Symbol for minim

Minim Use the metric system
mistaken as “mL”
x3d For three days Mistaken as “3 doses” Use “for three days”
Mistaken as opposite of
intended; mistakenly
More than and less Use “more than” or
> and < use incorrect symbol;
than “less than”
“< 10” mistaken as
“40”
Mistaken as the
number 1 (e.g., “25 Use “per” rather than a
Separates two doses
/ (slash mark) units/10 units” misread slash mark to separate
or indicates “per”
as “25 units and 110” doses
units)
9@ At Mistaken as “2” Use “at”
& And Mistaken as “2” Use “and”
+ Plus or and Mistaken as “4” Use “and”
Mistaken as a zero Use “hr,” “h,” or

° Hour
(e.g., q2° seen as q 20) “hour”
Use 0 or zero, or
Mistaken as numerals
Ф or ᴓ zero, null sign describe intent using
4, 6, 8, and 9
whole words
Page 20 of 20

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Date of Issue :

31. POLICY ON STANDARD ABBREVIATIONS FOR USE IN MEDICAL RECORDS AND

Acceptable Terms or Abbreviation Intended meaning

Wednesdays and Saturdays

Units of Measure and Concentration

ointment, oint Ointment

Approved medical abbreviations

ABG arterial blood gas

BPH benign prostatic hypertrophy

CPAP Continuous Positive Airway Pressure

ENT ears, nose, throat (otorhinolaryngology)

HgbA1c or A1c Glycosylated Hemoglobin

LVF left ventricular function

TTP thrombotic thrombocytopenic purpura

Banned Abbreviations in Medication chart documentation

µg Microgram Mistaken as “mg” Use “mcg”

BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime”

At bedtime, Use “half-strength”

International Mistaken as IV (intravenous) or

Mistaken as “right eye” (OD-

By mouth, The “os” can be mistaken as Use “PO,” “by

Mistaken as q.i.d., especially if

Nightly or at Use “nightly” or “at

Mistaken as “q.d.” (daily) or

Mistaken as q.i.d. (four times

Every evening Use “daily at 6 PM”

hours before surgery”

Sliding scale Spell out “sliding

Sliding scale Mistaken as selective-serotonin Spell out “sliding

Sliding scale Mistaken as Strong Solution of Spell out “sliding

i/d One daily Mistaken as “tid” Use “1 daily”

Mistaken as “3 times a day” or

Mistaken as the number 0 or 4,

Mistaken as unit dose (e.g.,

Dose Designations and Intended

Do not use trailing

Use zero before a

Drug name and dose run

The “m” is sometimes

Use commas for dosing

Demerol- Mistaken as diphtheria-

Mistaken as potassium Use complete drug name

Tylenol with Mistaken as

TNK TNKase Mistaken as “TPA” Use complete drug name

nitroglycerin Mistaken as sodium

“Norflox” norfloxacin Mistaken as Norflex Use complete drug name

Symbols Intended Meaning Misinterpretation Correction

Symbol for dram

Symbol for minim

9@ At Mistaken as “2” Use “at”

& And Mistaken as “2” Use “and”

+ Plus or and Mistaken as “4” Use “and”

Mistaken as a zero Use “hr,” “h,” or

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