Have you noticed how the ophthalmic community seems to talk in code? PT w/? IOP f/u VF OU. And sometimes we even make-up our own abbreviations system.
I once audited Evaluation and Management (E&M) chart notes and found that the technician would frequently use “BE.” I was confused as to what this could possibly mean. Then it was explained to me, BE = both eyes. It was a few days later that I also learned that BE in the medical world actually stands for barium enema!
To avoid confusion or even embarrassing mistakes, here are some of the most commonly used appropriate abbreviations. Use them to standardize documentation in the medical record.
When you are audited, the nurse reviewer will know exactly what you are referencing. And you might consider submitting this list along with your chart notes for easier interpretation.
| a.c. |
Before meals (ante cibum) |
| AAG |
Acute angle closure glaucoma |
| AC |
Anterior chamber |
| ACC |
Accommodative |
| ACG |
Angle closure glaucoma |
| ACIOL |
Anterior chamber IOL |
| ACT |
Alternate cover test |
| AFGE |
Air fluid gas exchange |
| AL |
Axial length |
| ALK |
Automated lamellar keratoplasty |
| ALT |
Argon laser trabeculoplasty |
| AMD |
Age-related macular degeneration |
| APCT |
Alternate prism + cover test |
| APD |
Afferent pupillary defect |
| Appl |
Applanation tension |
| ARMD |
Age related macular degeneration |
| ASC |
Ambulatory surgical center |
| AT |
Applanation tension |
| ATR |
Against-the-rule astigmatism |
| BDR |
Background diabetic retinopathy |
| b.i.d. |
Twice a day (bis in die) |
| C + S |
Culture and sensitivity |
| C/D |
Cup-to-disc ratio |
| CA |
Corneal abrasion |
| CACG |
Chronic angle closure glaucoma |
| D |
Diopter |
| D + N |
Distance and near |
| D&V |
Ductions and versions |
| F + F |
Fix and follow |
| f/u |
Follow-up |
| FA |
Fluorescein angiography |
| FB |
Foreign body |
| FH |
Family history |
| FTFC |
Full to finger counting |
| FTG |
Full-time glasses |
| FTP |
Full-time patch |
| GP |
Gas permeable |
| GPC |
Giant papillary conjunctivitis |
| GVF |
Goldmann visual field |
| H |
Hyperphoria |
| H + P |
History and physical |
| h.s. |
At bedtime (hora somni) |
| h/o |
History of |
| HA |
Headache |
| ICCE |
Intracapsular cataract extraction |
| ICG |
Indocyanine green angiography |
| IOL |
Intraocular lens |
| IOP |
Intraocular pressure |
| J J1 J2 |
Jaeger notation/size of type for near vision |
| JODM |
Juvenile onset diabetes mellitus |
| KCS |
Keratoconjunctivitis sicca |
| K-reading |
Measurement of corneal curvature with a keratometer |
| LASIK |
Laser in situ keratomileusis |
| LD |
Lattice degeneration |
| LL |
Lower lid |
| LLL |
Left lower lid |
| LLR |
Left lateral rectus |
| LMR |
Left medial rectus |
| LP |
Light perception |
| LP+P |
Light perception and projection |
| LT |
Left |
| MG |
Myasthenia gravis |
| MI |
Myocardial infarction; heart attack |
| MR |
Manifest refraction |
| MS |
Multiple sclerosis |
| N |
Near |
| N + V |
Nausea and vomiting |
| n.p.o. |
Nothing by mouth (nil per Os) |
| NI |
No improvement |
| NKA |
No known allergies |
| NKDA |
No known drug allergies |
| NI |
Normal |
| NLD |
Nasolacrimal duct |
| NLP |
No light perception |
| NML |
Normal |
| NPDR |
Non-proliferative diabetic retinopathy |
| NR |
Non-reactive |
| NS |
Nuclear sclerosis |
| NVM |
Neovascular membrane |
| OAG |
Open angle glaucoma |
| OHT |
Ocular hypertensive |
| OD |
right eye (oculus dexter) |
| OS |
Left eye (oculus sinister) |
| OU |
Both eyes (oculus uterque) |
| p.c. |
After meals |
| p.o. |
By mouth |
| p.p. |
After eating |
| PACT |
Prism + alternate cover test |
| PAM |
Potential acuity meter |
| PC |
Posterior capsule |
| PCIOL |
Posterior chamber IOL |
| PD |
Prism diopter |
| PDR |
Proliferative diabetic retinopathy |
| ph |
Pin hole |
| PI |
Peripheral iridectomy/iridotomy |
| PK |
Penetrating keratoplasty |
| pl |
Plano lens |
| PMH |
Past medical history |
| PMMA |
Polymethylmethacrylate |
| p/o |
Postoperatively |
| POAG |
Primary open angle glaucoma |
| PPL |
Pars plana lensectomy |
| PPV |
Pars plana vitrectomy |
| PRK |
Photorefractive keratectomy |
| PRP |
Pan retinal photocoagulation |
| PSC |
Posterior subcapsular cataract |
| q.a.m. |
Every day before noon |
| q.d. |
Every day |
| q.h. |
Every hour |
| q.h.s. |
At bedtime |
| q.i.d. |
4 times a day |
| q.n. |
Every night |
| q.o.d. |
Every other day |
| q.p.m. |
Every day after noon |
| RA |
Rheumatoid arthritis |
| RAPD |
Relative afferent papillary defect |
| RD |
Retinal detachment |
| REF |
Refraction |
| REM |
Rapid eye movement |
| RET |
Retinoscopy |
| RGP |
Rigid gas permeable |
| RIO |
Right inferior oblique |
| RIR |
Right inferior rectus |
| RK |
Radial keratotomy |
| RLL |
Right lower lid |
| RLR |
Right lateral rectus |
| RMR |
Right medial rectus |
| ROP |
Retinopathy of prematurity |
| ROS |
Review of systems |
| RP |
Retinitis pigmentosa |
| R&R |
Recess and resect |
| RSO |
Right superior oblique |
| RSR |
Right superior rectus |
| RT |
Right eye |
| RTC |
Return to clinic |
| RUL |
Right upper eyelid |
| RX |
Treatment – glasses, medicine, etc |
| RXT |
Right exotropia |
| SCC |
Squamous cell carcinoma |
| SCL |
Soft contact lens |
| SO |
Superior oblique |
| SOB |
Short of breath |
| SCODI |
Scanning computerized ophthalmic diagnostic imaging |
| SPH |
Sphere |
| SPK |
Superficial punctate keratitis |
| SR |
Superior rectus |
| SRNV |
Subretinal neovascular membrane |
| stat. |
Immediately |
| Sub.q. |
Subcutaneous (under the skin) |
| Sx |
Symptoms |
| T |
Tension |
| TA |
Tension by applanation |
| TBT |
Tear break-up time |
| TM |
Trabecular meshwork |
| Trab |
Trabeculectomy |
| TRD |
Traction retinal detachment |
| Tx |
Treatment |
| ung |
Ointment |
| VA |
Visual acuity |
| VF |
Visual field |
| Vit |
Vitreous |
| x |
Exophoria at distance |
| XT |
Exotropia at distance |
| YAG |
Yttrium-aluminum-garnet laser |
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About the author: This article has been adapted from the January 2006 issue of Techniques. It was written by Academy Coding Executive Sue Vicchrilli, COT, OCS.
