Clinical Record Abbreviations (By Category)


BINOCULAR VISION CONTACT LENSES EXAMINATION FINDINGS
EXAMINATION TESTS PRESCRIPTION EYEWEAR LABORATORY TESTS
LOW VISION MISCELLANEOUS MEDICATION/VITAMIN/DROP
OCULAR CONDITIONS OCULAR STRUCTURES PRESCRIPTION WRITING
RECORD KEEPING SYSTEMIC CONDITIONS SURGICAL PROCEDURES

BINOCULAR VISION
AbdAbduction
ACAAccommodation-Convergence ratio
AccAccommodation
AddAdduction
AltAlternate/Alternating (strabismus)
AMBLAmblyopia
AmpsAmplitudes
ARCAnomalous Retinal Correspondence
EEsophoria at distance (6M)
E(T)Intermittent Esotropia at distance (6M)
E(T)'Intermittent Esotropia at near (40cm)
E'Esophoria at near (40 cm)
EFEccentric Fixation
ETEsotropia at distance (6M)
ET'Esotropia at near (40 cm)
Int.Intermittent
NPANear Point of Accommodation
NPCNear Point of Convergence
NRANegative Relative Accommodation
PPUPencil Push Ups
VTVisual Therapy/Training
XExophoria at distance (6M)
X(T)Intermittent Exotropia at dist.(6M)
X(T)'Intermittent Exotropia at near (40cm)
X'Exophoria at near (40 cm)
XTExotropia at distance (6M)
XT'Exotropia at near (40 cm)
CONTACT LENSES
B.C. / BCBase Curve
BAKBenzalkonium Chloride
CLContact Lens
CSCare System
DWDaily Wear
EWExtended Wear
FTWFull Time Wear
FWFlex Wear
HCLHard Contact Lens
IIntermediate
ICIntermediate Curve
OADOverall Diameter
OZDOptical Zone Diameter
PCPeripheral Curve
PMMAPolymethylmethacrylate
R / rRadius
RGP/GP/RCLRigid Gas Permeable Contact
SCSecondary Curve
SCSecondary Curve
SCLSoft Contact Lens
WWidth
WSWearing Schedule (CL)
WTWearing Time
EXAMINATION FINDINGS
___
cc
With Correction
___
sc
Without Correction
A/VArtery to Vein Ratio
AbnAbnormal
APDAfferent Pupillary Defect
AR/ATRAgainst The Rule (astigmatism)
BCCBalance Cross Cylinder
BlephBlepharitis
BPM / bpmBeats Per Minute
BVABest Visual Acuity
C/DCup-to-Disc Ratio
CCCCentral Corneal Clouding
CCMCoverage, Centration, Movement
CCTCentral Corneal Thickness
CFCount Fingers
CL / clClear
CSMEClinically Significant Macular Edema
D & QDeep and Quiet
D/CDeep and Clear
DD / ddDisc Diameter
DVADistance Vision
EVEccentric Viewing
F/IFlat and Intact
FBForeign Body
FBSForeign Body Sensation
FCFinger Counting
FR / FLRFoveal Light Reflex
FROMFull Range Of Motion
FTFCFull To Finger Counting
GPCGiant Papillary Conjunctivitis
HemeHemorrhage
HMHand Motion
HVIDHorizontal Visible Iris Diameter
IOPIntraocular Pressure
IRMAIntraretinal Microvascular Abnormalities
KPKeratic Precipitate
LPLight Perception
Lproj / LPcPLight Projection / Light Perception with Projection
MManifest Refraction
MACMinimal Apical Clearance
MCARMires Clear & Regular
MEMacular Edema
MGMarcus Gunn Pupil
NLPNo Light Perception
NRCNormal Retinal Correspondence
NSNuclear Sclerosis
NVANear Vision
NVDNeovascularization of the Disc
NVENeovascularization of the Retina Elsewhere
NVINeovascularization of the Iris
NVMNeovascular Membrane
PASPeripheral Anterior Synechiae
PEDPigmentary Epithelial Detachment
PERRLAPupils Equal Round Reactive to Light and Accommodation
PFDPalpebral Fissure Depth
PHNIPinhole No Improvement
PPMPersistent Pupillary Membrane
PSPosterior Synechiae
PSCPosterior Subcapsular Cataract
PVDPosterior Vitreal Detachment
RDRetinal Detachment
SAFE/FESASmooth Accurate Full Extensive
SEISubepithelial Infiltrate
SPKSuperficial Punctate Keratitis
SRNVMSubretinal Neovascular Membrane
SVPSpontaneous Venous Pulsation
TIDTransillumination Defects
WR / WTRWith the Rule (astigmatism)
   ___
W s P
White Without Pressure
EXAMINATION TESTS
BIOBinocular Indirect Ophthalmoscopy
BPBlood Pressure
CFConfrontation Fields
CTCover Test
CVColor Vision
D & IDilation and Irrigation
DFEDilated Fundus Examination
EOGElectro-oculogram
EOMExtraocular Muscle
ERGElectroretinogram
FAFluorescein Angiography
FANGFluorescein Angiogram
GVFGoldmann Visual Field
JJaeger Near Acuity
JCCJackson Cross Cylinder
KKeratometry
LOGLogmar Acuity Chart
MEMMonocular Estimate Method
MOTMotility
NCTNon-Contact Tonometry
OKNOptokinetic Nystagmus
ORx Over Refraction
PPachymetry
PAMPotential Acuity Meter
PHPinhole
PSRTPhotostress Recovery Test
RRetinoscopy
R-GRed-Green
SLESlit Lamp Examination
StereoStereopsis
STT 1Schirmer Tear Test 1
STT 2Schirmer Tear Test 2
STTBBasal Schirmer Tear Test
Ta / TaGTonometry /Goldmann Tonometry
TBUTTear Break Up Time
TVFThreshold Visual Field
VAVisual Acuity
VEPVisual Evoked Potential
VFVisual Fields
W 4-DotWorth Four Dot Fusion Test
PRESCRIPTION EYEWEAR
BDBase Down
BIBase In
BOBase Out
BUBase Up
CHACompound Hyperopic Astigmatism
CMACompound Myopic Astigmatism
CylCylinder
DDiopter
DBLDistance Between Lenses
DORx/DVODistance Only Prescription
FTFlat-Top Bifocal
IPDInterpupillary Distance (PD)
MAMixed Astigmatism
MPDMonocular Pupillary Distance
NVONear Vision Only (Rx)
OCOptical Center
PALProgressive Addition Lens
PDInterpupillary Distance
PL Plano
RORxReading Only Prescription
S / SphSphere
SHSimple Hyperope
SMSimple Myope
SMASimple Myopic Astigmatism
SRxSpectacle Prescription
UVUltraviolet
LABORATORY TESTS
ACEAngiotensin Converting Enzyme
BUNBlood Urea Nitrogen
C & SCulture and Sensitivity
CBCComplete Blood Count
ELISAEnzyme-Linked Immunosorbent assay
ERSErythrocyte Sedimentation Rate
FBSFasting Blood Sugar
FTA-ABSFluorescent Treponemal Antibody Absorption Test
GTTGlucose Tolerance Test
HbHemoglobin
HDLHigh Density Lipoprotein
LDLLow Density Lipoprotein
MRIMagnetic Resonance Imaging
OGTTOral Glucose Tolerance Test
RFRheumatoid Factor
VDRLVenerial Disease Research Laboratory
LOW VISION
EVEccentric Viewing
HHMHand Held Magnifier
MSMicroscope
PDTPhotodynamic Therapy
SMStand Magnifier
TMSTelemicroscope
TSTelescope
MISCELLANEOUS
___
c
with
___
s
Without
b/cBecause
b/t / btwBetween
CRTComputer
FDAFood and Drug Administration
HgMercury
Hr / HHour
Lt /LLeft
MMonth
Rt /RRight
S/PStatus Post (previous)
STATImmediately
VDTVideo Display Terminal (computer)
w/With
w/iWithin
w/oWithout
YYear
> / <Greater than / Less than
MEDICATION/VITAMIN/DROP
ASAAspirin
ATArtificial Tears
CAICarbonic Anhydrase Inhibitor
HCTZHydrochlorothiazide
KPotassium
OC / BCOral Contraceptive/Birth Control
PCNPenicillin
OCULAR CONDITIONS
ACGAngle Closure Glaucoma
AIONAnterior Ischemic Optic Neuropathy
AMD/ ARMDAge-related Macular Degeneration
BRAOBranch Retinal Artery Occlusion
CAGClosed Angle Glaucoma
CATCataract
CMECystoid Macular Edema
CMVCytomegalovirus
CNAGChronic Narrow Angle Glaucoma
CNVMChoroidal Neovascular Membrane
COAGChronic Open Angle Glaucoma
CRAOCentral Retinal Artery Occlusion
CRVOCentral Retinal Vein Occlusion
CSRCentral Serous Retinopathy
EKCEpidemic Keratoconjunctivitis
GLCGlaucoma
HRHypertensive Retinopathy
HSKHerpes Simplex Keratitis
IKInterstitial Keratitis
KCKeratoconus
KCSKeratoconjuctivitis Sicca
LVLow Vision
MFSMonocular Fixation Syndrome
MGDMeibomian Gland Disfunction
NAGNarrow Angle Glaucoma
NTGNormal Tension Glaucoma
OAGOpen Angle Glaucoma
OHTNOcular Hypertension
PCFPharyngeal Conjunctival Fever
PDRProliferative Diabetic Retinopathy
PHPVPersistent Hyperplastic Primary Vitreous
PMDPellucids Marginal Degeneration
POAGPrimary Open Angle Glaucoma
POHS / OHSPresumed Ocular Histoplasmosis Syndrome
RBONRetrobulbar Optic Neuritis
SLKSuperior Limbic Keratoconjunctivitis
StrabStrabismus
OCULAR STRUCTURES
ACAnterior chamber
B conj.Bulbar Conjunctiva
CBCiliary Body
Conj.Conjunctival
FAZFoveal Avascular Zone
IOInferior Oblique
IRInferior Rectus
KCornea
L / LL / ULLid / Lower Lid / Upper Lid
L/LLids / Lashes
LRLateral Rectus
MRMedial Rectus
ONHOptic Nerve Head
P Conj.Palpebral Conjunctival
SL Schwalbe's Line
SOSuperior Oblique
SRSuperior Rectus
SSScleral Spur
TMTrabecular Meshwork
PRESCRIPTION WRITING
b.i.d. / bidTwice a day 'bis in die"
D / dDay
g / gmgram
gt / gttsDrop / Drops
h.s. / hsAt bedtime
p.c. / pcAfter Meals
p.o. / poBy Mouth
PRNAs Needed
qEvery
q.d. / qdDaily
q.i.d. / qidFour Times Per Day
q.o.d. / qodEvery Other Day
RxPrescription
SigLabel
t.i.d. / tidThree Times Per Day
ung. / ungOintment
W/WkWeek
RECORD KEEPING
A/PAssessment and Plan
ASAPAs Soon As Possible
BIRTBurning, Itching, Redness,Tearing
c/oComplains of
CCChief Complaint
Cong.Congenital
DDistance
D/CDiscontinue
DDxDifferential Diagnosis
DOBDate of Birth
DPADiagnostic Pharmaceutical Agents
DxDiagnosis
EdEducation
ETDRSEarly Treatment Diabetic Retinopathy Study
ETOHEthanol
F/FFlashes and Floaters
F/UFollow-Up
FHxFamily History
FOHxFamily Ocular History
GlcGlucose
H/OHistory of
HPIHistory of Present Illness
HxHistory
ICAInternal Carotid Artery
LASLeft Arm Seated
LatLateral
LEELast Eye Examination
LME /LPELast Medical Exam/Last Physical Examination
mmHgMillimeters Mercury
MxManagement
NNear
NINo Improvement
NKA/NKDA/NKMANo Known Allergies/No Known Drug / Medical Allergies
O.D.Doctor of Optometry
ODRight Eye "oculus dexter"
OFHxOcular Family History
OHxOcular History
OSLeft Eye "oculus sinister"
OUBoth Eyes "oculus uterque"
P / PtPatient
PCPPrimary Care Physician
PDPrism Diopter
PedPediatrician
PRPoor Responder
PRProgress Report
PxPrognosis
R/ORule Out
RAS / LASRight Arm Seated
REERoutine Eye Exam
ROSReview of System
RTCReturn To Clinic
RxnReaction
S/SSigns and Symptoms
SHxSocial History
SOAPESubjective, Objective, Assessment, Plan and Education
TDxTentative Diagnosis
W/UWork Up
WC/LSWarm Compresses and Lid Scrubs
WD/wdWorking Distance
SYSTEMIC CONDITIONS
AIDSAcquired Immune Deficiency Syndrome
AODMAdult Onset Diabetes Mellitus
BDRBackground Diabetic Retinopathy
CACancer/Carcinoma
CHFCongestive Heart Failure
COPDChronic Obstructive Pulmonary Disease
CVACerebrovascular Accident
DMDiabetes Mellitus
GDMGestational Diabetes Mellitus
HAHeadache
HIVHuman Immunodeficiency Virus
HTNHypertension
HZVHerpes Zoster Virus
IDDMInsulin Dependent Diabetes Mellitus
JODMJuvenile Onset Diabetes Mellitus
MaMicroaneurysm
MIMyocardial Infarction
MSMultiple Sclerosis
NIDDMNon-Insulin Dependent Diabetes Mellitus
NPDRNonproliferative Diabetic Retinopathy
RARheumatoid Arthritis
SLESystemic Lupus Erythematosus
TBTuberculosis
TIATransient Ischemic Attacks
TMJTemporal Mandibular Joint
URIUpper Respiratory Infection
UTIUrinary Tract Infection
SURGICAL PROCEDURES
ALTArgon Laser Trabeculoplasty
ECCEExtracapsular Cataract Extraction
ICCEIntracapsular Cataract Extraction
IOLIntraocular Lens
LPILaser Peripheral Iridotomy
LTPLaser Trabeculoplasty
PIPeripheral Iridectomy
PRPPan Retinal Photocoagulation