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.