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Data Standards and Data Dictionary

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The main list consists of over 600 words/terms and their recommended abbreviations/symbols.

Character Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
^Above or elevated
&And
Approximately
@At
=Equals
>Greater than, more, or more than
<Less or less than
-Negative or minus
#Number or pound(s)
+Plus or positive
XTimes

Letter A Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
A FIBAtrial fibrillation
A FLUTTERAtrial flutter
A&PAuscultation & percussion
A/PAbdomen/Pelvis
AAAfrican American
ABAntibody
ABDAbdomen (abdominal)
ABGArterial blood gases
ABNAbnormal
ABNLAbnormal
ABSAbsent/Absence
ABSTAbstract/Abstracted
ABXAntibiotics
ACAdrenal cortex
ACBEAir contrast barium enema
ACHAdrenal cortical hormone
ACID PHOSAcid phosphatase
A-COLONAscending Colon
ACTHAdrenocorticotrophic hormone
ADENOCAAdenocarcinoma
ADENOPAdenopathy
ADHAntidiuretic hormone
ADHAtypical ductal hyperplasia 
ADJAdjacent
ADLActivities of daily living
ADMAdmission/Admit
ADRAdverse drug reaction
AFFAffirmative
AFPAlpha-fetoprotein
AGAntigen
AGLAcute granulocytic leukemia
AIAromatase inhibitor
AIAtrial stenosis/insufficiency/incompetence
AIDSAcquired Immune Deficiency Syndrome
AIHAAutoimmune hemolytic anemia
AIN III or AIN 3Anal intraepithelial neoplasia, grade III
AK(A)Above knee (amputation)
AKAAlso known as
ALBAlbumin
ALK PHOSAlkaline phosphatase
ALLAcute lymphocytic leukemia
ALNDAxillary Lymph node dissection
ALSAmyotrophic lateral sclerosis
AMBefore noon
AMAAgainst medical advice
AMBAmbulatory
AMIAcute myocardial infarction
AMLAcute myelogenous leukemia
AMPAmputation
AMTAmount
ANAPAnaplastic
ANGIOAngiography/Angiogram
ANSAutonomic nervous system
ANTAnterior
AODMAdult-onset Diabetes Mellitus
APAbdominal perineal
A-PAnteroposterior
APCAtrial premature complexes
APPAppendix
APPL’YApparently
ARCAIDS-related condition (complex)
ARDAIDS-related disease
ARDSAcute Respiratory Distress (Disease) Syndrome
ARFAcute renal failure
ARRHYArrhythmia
ARTArtery (ial)
ASArteriosclerosis/Arteriosclerotic
ASAAspirin, Acetylsalicylic acid
ASAPAs soon as possible
ASCVDArteriosclerotic cardiovascular disease
ASHDArteriosclerotic heart disease
ASPAspiration
ASPVDArteriosclerotic Peripheral Vascular Disease
ASSOCAssociated
A-STENAortic stenosis
ATNAcute tubular necrosis
ATPAdenosine triphosphate
ATRAchilles tendon reflex
AUTAutopsy
AVArteriovenous
AVGAverage
AVMArteriovenous malformation
AXAxilla(ry)
AXLNDAxillary Lymph node dissection

Letter B Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
B/FBlack female
B/LBilateral
B/MBlack male
BABarium
BADBipolar affective disorder
BCCBasal cell carcinoma
BCGBacillus Calmette-Guerin
BDBile duct
BEBarium enema
BFBlack female
BIDTwice a day (daily)
BILBilateral
BK(A)Below knee (amputation)
B/LBilateral
BMBlack Male
BMBone marrow
BMBowel movement
BMBXBone marrow biopsy
BMIBody mass index
BMTBone marrow transplant
BNABlock Numbering Area
BOTBase of tongue
BPBlood pressure
BPHBenign prostatic hypertrophy/hyperplasia
BRBloom-Richardson
BRACHYBrachytherapy
BRBPRBright red blood per rectum
BRCA 1 and BRCA 2Breast cancer susceptibility gene
BRMBiological response modifier
BROBrother
BSABody surface area
BSCBone scan
BSOBilateral salpingo-oophorectomy
BTBladder tumor or Brain tumor
BUNBlood urea nitrogen
BUSBartholin's, Urethral & Skene's
BVBlood volume
BXBiopsy

Letter C Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
C/A/PChest, abdomen, pelvis
C/OComplaint (-ning) of
C/WConsistent with
C1-C7Cervical vertebrae
CACalcium
CACarcinoma
CA 125Cancer antigen 125
CA 19-9Carbohydrate antigen 19-9
CA++Calcification(s)
CABGCoronary artery bypass graft
CADCoronary artery disease
CALC(S)Calcification(s)
CAP(S)Capsule(s)
CBCComplete blood count
CCChief complaint or Cubic centimeter
CCUCoronary care unit
CEACarcinoembryonic antigen
CFCystic fibrosis
CFNCentimeters from nipple
CGASerum chromogranin A
CGLChronic granulocytic leukemia
CGYCentigray
CHDCongenital heart disease
CHEMOChemotherapy
CHFCongestive heart failure
CHGChange
CHRChronic
CIGCigarettes
CINCervical intraepithelial neoplasia
CIN III or CIN 3Cervical intraepithelial neoplasia, grade III
CISCarcinoma in situ
CISHChromogenic in situ hybridization
CLLChronic lymphocytic leukemia
CLRClear
CMCentimeter
CMLChronic myeloid (myelocytic) leukemia
CNSCentral nervous system
CO60Cobalt 60
COLDChronic obstructive lung disease
CONTContinue/continuous
CONTRAContralateral
COPDChronic obstructive pulmonary disease
CPTCurrent Prodedural Terminology (codes)
CRCCyclic redundancy code
CRFChronic renal failure
CRMCircumferential resection margin
CSCollaborative stage
CSFCerebrospinal fluid
C-SFColony stimulating factor
C-SPINECervical spine
CTCAT/CT scan/Computerized axial tomography
CTCCirculating tumor cells
CUCChronic ulcerative colitis
CVACerebrovascular accident
CVDCardiovascular disease
CXRChest X-ray
CYSTOCystoscopy
CYTOCytology

Letter D Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
D&CDilatation and curettage
D/CDischarge
D/TDue to
DCDiscontinue(d)
DCISDuctal carcinoma in situ
DCODeath Certificate Only
D-COLONDescending colon
DDXDifferential diagnosis
DECRDecrease(d)
DERMDermatology
DESDiethylstilbestrol
DIAMDiameter
DICDisseminated intravascular coagulopathy
DIFFDifferentiated/differential
DISCHDischarge
DJDDegenerative joint disease
DKDon't/Doesn't know
DMDiabetes mellitus
DNADeoxyribonucleic acid
DOADead on arrival
DOBDate of birth
DODDate of death
DOEDyspnea on exertion
DREDigital rectal examination
DTCDisseminated tumor cells
DTRDeep tendon reflex
DVTDeep vein thrombosis
DXDiagnosis
DZDisease

Letter E Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
E.G.For example
E/OEvidence of
EBRTExternal beam radiotherapy
ECG/EKGElectrocardiogram
EDEmergency department
EEGElectroencephalogram
EENTEye, ear, nose, throat
EGDEsophagogastro-duodenoscopy
EGFREpidermal growth factor receptor
ELEVElevated
EMGElectromyogram
ENLEnlarged
ENLGDEnlarged
ENTEars, nose, and throat
EODExtent of Disease
EREmergency room
ER(A)Estrogen receptor (assay)
ERCPEndoscopic retrograde cholangiopancreatography
ESRDEnd stage renal disease
ETOHAlcohol
EUAExam under anesthesia
EVElectron volt
EVALEvaluation
EXAMExamination
EXC(D)Excision/excised
EXPExpired
EXP LAPExploratory laparotomy
EXPLExploratory
EXPL LAPExploratory laparotomy
EXTExtend/extension

Letter F Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
FAPFamilial adeomatous polyposis
FCOTFirst course of treatment
FHXFamily History
FISHFluorescence in situ hybridization
FLFluid
FLIPIFollicular lymphoma international prognostic index
FLOW CYTOFlow cytometry
FLUROFluoroscopy
FNAFine needle aspiration
FNABFine needle aspiration biopsy
FOMFloor of mouth
FREQFrequent/Frequency
FSFrozen section
FTSGFull thickness skin graft
FUFollow-up
FUOFever of unknown origin
FXFracture
FX(S)Fractions(s)

Letter G Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
GBGallbladder
GEGastroesophageal
GENGeneral/Generalized
GERDGastroesophageal reflux disease
GIGastrointestinal
GISTGastrointestinal stromal tumors
GRGrade
GUGenitourinary
GYGray
GYNGynecology

Letter H Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
H&EHematoxylin and Eosin
H&PHistory and physical
H/HHemoglobin and hematrocrit
H/OHistory of
HAVHepatitis A (virus)
HBVHepatitis B (virus)
HCGHuman chorionic gonadotropin
HCTHematocrit
HCVHepatitis C (virus)
HCVDHypertensive cardiovascular disease
HDRHigh dose rate
HDVHepatitis D (virus)
HEM/ONCHematology/Oncology (ist)
HEP AHepatitis A (virus)
HEP BHepatitis B (virus)
HEP CHepatitis C (virus)
HEP DHepatitis D (virus)
HER2Human epidermal growth factor receptor 2
HFHispanic female
HGBHemoglobin
HGSILHigh grade squamous intraepithelial lesion
HIVHuman Immunodeficiency Virus
HMHispanic male
HORMHormone
HOSPHospital
HPIHistory of present illness
HPVHuman Papilloma Virus
HR(S)Hour/Hours
HRTHormone replacement therapy
HSMHepatosplenomegaly
HTLVHuman T-Lymphotrophic Virus, (Type III)
HTNHypertension
HVDHypertensive vascular disease
HXHistory
HYSTHysterectomy

Letter I Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
I&DIncision & drainage
I-131Iodine 131
IBDInflammatory bowel disease
ICBIntracavitary brachytherapy
ICMIntercostal margin
ICSIntercostal space
ICUIntensive care unit
IDCInfiltrating/invasive ductal carcinoma
IDDMInsulin-dependent diabetes mellitus
IGImmunoglobulin
IHCImmunohistochemical
IHSSIdiopathic hypertrophic subaortic stenosis
ILDInterstitial lung disease
IMIntramuscular
IMPImpression
IMRTIntensity modulated radiation therapy
INCLIncludes/Including
INCRIncrease(d)
INFInferior
INFILInfiltrating
INFILTInfiltrating
INPTInpatient
INTInternal
INVInvade(s)/invading/invasion
INVLInvolve(s)/involvement/involving
IPInpatient
IPIInternational prognostic index (for lymphoma)
IPPBIntermittent positive pressure breathing
IPSInternational prognostic score
IPSIIpsilateral
IRREGIrregular
ITIntrathecal
ITCIsolated tumor cells
ITPIdiopathic thrombocytopenia
IVIntravenous
IVCInferior vena cava
IVCAIntravenous cholangiogram
IVPIntravenous pyelogram

Letter J Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
JAK2Janus kinase 2
JRAJuvenile rheumatic arthritis
JVDJugular venous distention

Letter K Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
KGKilogram
KSKaposi sarcoma
KUBKidneys, ureters, bladder
KVKilovolt

Letter L Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
L1-L5Lumbar vertebra
LABLaboratory
LADLymphadenopathy
LANLymphadenopathy
LAPLaparotomy
LATLateral
LAVLymphadenopathy-associated virus
LB(S)Pound(s)
LBBBLeft bundle branch block
LCISLobular carcinoma in situ
LCMLeft costal margin
LDHLactic dehydrogenase
LDRLow dose rate
LELower extremity
LFTLiver function test
LINLaryngeal intraepithelial neoplasia
LINACLinear accelerator
LIQLower inner quadrant
LLELeft lower extremity
LLLLeft lower lobe
LLQLeft lower quadrant
LMPLast menstrual period
LN(S)Lymph node(s)
LNDLymph node dissection
LOQLower outer quadrant
LPNLicensed practical nurse
LRGLarge
LSLumbosacral
LSOLeft salpingo-oophorectomy
L-SPINELumbar spine
LS SCANLiver/spleen scan
LTLeft
LUELeft upper extremity
LULLeft upper lobe
LUOQLeft upper outer quadrant
LUQLeft upper quadrant
LVILymph/vascular invasion / Lymphovascular invasion

Letter M Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
M/DIFFModerately differentiated
MALMalignant
MALIGMalignant
MAMMOMammogram
MANDMandible/mandibular
MATMultifocal atrial tachycardia
MAXMaximum
MCMedical center
MC(H)Millicurie (hours)
MCGMicrogram
MCIDMixed combined immunodeficiency
M-CSFMacrophage colony-stimulating factor
MCNMucinous cystic neoplasm
MCTDMixed connective tissue disease
MDModerately differentiated
MDSMyelodysplastic syndrome
MEDMedication
MED ONCMedical oncology (ist)
METSMetastatic/Metastasis
MEVMillion electron volts
MGMyasthenia gravis
MG(H)Milligram (hours)
MGFMaternal grandfather
MGMMaternal grandmother
MGUSMonoclonal gammaopathy of uncertain significance
MIMyocardial infarction
MIBBMinimally invasive breast biopsy
MICROMicroscopic
MINMinimum
MINMinute
MISMelanoma in situ
MLMiddle lobe
MLMilliliter
MMMilliliter
MMGMammogram
MO(S)Months
MODModerate(ly)
MOD DIFFModerately differentiated
MPVCMultifocal premature ventricular contraction
MRCPMagnetic resonance cholangiopancreatography
MRIMagnetic resonance imaging
MRMModified radical mastectomy
MRSAMethicillin Resistant Staphylococcus Aureus
MSMultiple sclerosis
MSBMain stem bronchus
MSIMicrosatellite instability
MULTMultiple
MVMegavolt
MVPMitral valve prolapse

Letter N Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
N&VNausea and vomiting
N/ANot applicable
N/VNausea and vomiting
NANot applicable
NENo evidence
NECNot elsewhere classified
NEDNo evidence of disease
NEGNegative
NEOPLNeoplasm
NETNeuroendocrine tumor
NEURONeurology
NHNursing home
NHLNon-Hodgkin lymphoma
NIDDMNon insulin dependent diabetes mellitus
NLNormal
NMLNormal
NORMNormal
NOSNot otherwise specified
NRNot recorded
NRNot reportable
NSCCANon small cell carcinoma
NSCLCNon small cell lung carcinoma
NSFNo significant findings
NVDNeck vein distention

Letter O Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
OBObstetrics
OBSOrganic brain syndrome
OBSTObstructed (-ing, -ion)
ONCOncology (ist)
OPOutpatient
OP RPTOperative report
OROperating room
ORTHOOrthopedics
OTOOtology
OUTPTOutpatient
OZOunce

Letter P Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
P/DIFFPoorly differentiated
P32Phosphorus 32
PACPremature atrial contraction
PALPPalpated (-able)
PAPPapanicolaou smear
PAPPapillary
PATHPathology
PBSCTPeripheral blood stem cell transplant
PCPPrimary care physician
PCVPolycythemia vera
PDPoorly differentiated
PEPhysical examination
PEDSPediatrics
PERCPercutaneous
PETPositron emission tomography
PGFPaternal grandfather
PGMPaternal grandmother
PIDPelvic inflammatory disease
PIN III or PIN 3Prostatic intraepithelial neoplasia, grade III
PLTPlatelets
PMHPast/personal (medical) history
PMPPrimary medical physician
PNSPeripheral nervous system
POOR DIFFPoorly differentiated
POSPositive
POSSPossible
POSTPosterior
POST OPPostoperative(-ly)
PPDPacks per day
PRPer rectum
PR(A)Progesterone receptor (assay)
PRE OPPreoperative(-ly)
PREVPrevious
PROBProbable (-ly)
PROCTOProctoscopy
PSPerformance status
PSAProstatic specific antigen
PTPatient
PTPhysiotherapy/Physical therapy
PTAPrior to admission
PTCPercutaneous transhepatic cholecystogram
PTCCPapillary transitional cell carcinoma
PUDPeptic ulcer disease
PULMPulmonary
PVDPeripheral vascular disease
P VERAPolycythemia vera
PYPack years

Letter Q Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
QEvery
QDEvery day
QUADQuadrant

Letter R Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
R/ORule out
RARheumatoid arthritis
RADRadiation absorbed dose
RAD ONCRadiation Oncology
RAEBRefractory anemia with excess blasts
RAIRadioactive iodine
RAIURadioactive iodine uptake
RALRobotic assisted laparoscopy
RARPRobotic assisted radical prostatectomy
RBBBRight bundle branch block
RBCRed blood cells (count)
RCCRenal cell carcinoma
RCMRight costal margin
RCSReticulum cell sarcoma
RERegarding
RECRecommend
REC’DReceived
REFRACT ANEMRefractory anemia
REGRegional
REGRegular
RESECResection (ed)
RHDRheumatic heart disease
RIARadioimmunoassay
RIQRight inner quadrant
RLERight lower extremity
RLLRight lower lobe
RLQRight lower quadrant
RMCRegional medical center
RMLRight middle lobe
ROFReview of outside films
RONCRadiation Oncology
ROQRight outer quadrant
ROSReview of outside slides
RRPRadical retropubic prostatectomy
RSORight salpingo-oophorectomy
RSRRegular sinus rhythm
RTRadiation therapy
RTRight
RUERight upper extremity
RULRight upper lobe
RUQRight upper quadrant
RXPrescription
RXTRadiation therapy

Letter S Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
S/PStatus post
S1-S5Sacral vertebra
SATISSatisfactory
SBSmall bowel
SCCSquamous cell carcinoma
SCFSupraclavicular fossa
SCIDSevere combined immunodeficiency syndrome
S-COLONSigmoid colon
SCTStem cell transplant
SCVSupraclavicular
SGOTSerum glutamic oxaloacetic transaminase
SGPTSerum glutamic pyruvic transaminase
SHSocial history
SHXSocial history
SIADHSyndrome of inappropriate ADH
SIG COLONSigmoid colon
SILSquamous intraepithelial lesion
SIN III or SIN 3Squamous intraepithelial neoplasia
SLESystemic lupus erythematosus
SLLSmall lymphocytic lymphoma
SLNSentinel lymph node
SLNBXSentinel lymph node biopsy
SMSmall
SmCCSmall cell carcinoma
SOSalpingo-oophorectomy
SOBShort(ness) of breath
SPECSpecimen
SPEPSerum protein electrophoresis
SQSquamous
SSSummary stage
SSFSite Specific Factor
S-SPINESacral spine
SSSSick sinus syndrome
STSGSplit thickness skin graft
SQCCSquamous cell carcinoma
SUBCUSubcutaneous
SUBQSubcutaneous
SUGGSuggestive
SURGSurgery/Surgical
SUSPSuspicious/suspected
SVCSuperior vena cava
SXSymptoms

Letter T Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
T1-T12Thoracic vertebra
TAHTotal abdominal hysterectomy
TAH-BSOTotal abdominal hysterectomy- bilateral salpingo-oophorectomy
TBTuberculosis
TBTumor board
TCCTransitional cell carcinoma
T-COLONTransverse colon
TIATransient ischemic attack
TNMTumor, node, metastatis
TOBTobacco
TRANS-COLONTransverse colon
TRUSTransrectal ultrasound
TSTumor size
T-SPINEThoracic spine
TTPThromboticthrombocytopenia purpura
TURTransurethral resection
TURBTransurethral resection bladder
TURPTransurethral resection prostate
TVCTrue vocal cord
TVHTotal vaginal hysterectomy
TXTreatment

Letter U Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
UEUpper extremity
UGIUpper gastrointestinal (series)
UIQUpper inner quadrant
UNDIFFUndifferentiated
UNKUnknown
UOQUpper outer quadrant
URIUpper respiratory infection
USUltrasound
UTIUrinary tract infection

Letter V Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
VAGVagina/Vaginal
VAG HYSTVaginal hysterectomy
VAIN III or VAIN 3Vaginal intraepithelial neoplasia (grade III)
VIN III or VIN 3Vulvar intraepithelial neoplasia (grade III)
VGPVertical growth phase
VGRVertical growth rate
VSVital signs

Letter W Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
W/With
W/DIFFWell differentiated
W/FWhite female
W/MWhite male
W/OWithout
W/UWork-up
WBCWhite blood cells (count)
WDWell differentiated
WELL DIFFWell differentiated
WFWhite female
WK(S)Week(s)
WLWeight loss
WMWhite male
WNLWithin normal limits
WPWWolff-Parkinson-White syndrome
WTWeight

Letter X Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
XRXray
XRTExternal radiation therapy

Letter Y Abbreviations/Symbols

Abbreviation/SymbolWord/Term(s)
Y/OYear old
YOYear old
YR(S)Year(s)