Common terms and abbreviations in clinical files

Common terms and abbreviations in clinical files

Term/abbreviation

Meaning

ADLs

Activities of daily living (e.g. dressing, showering, eating, cooking etc)

Ax

Assessment

BD

Twice daily (medication frequency)

BPAD

Bipolar affective disorder

BPD

Borderline personality disorder

C/O

Complained of

CAT team/CATT

Crisis Assessment and Treatment team

CCU

Community care unit – supported accommodation for people with mental illness, with onsite mental health clinical services

CLZ

Clozapine an (anti-psychotic medication)

D&A

Drugs and alcohol

D/C

Discharge (from hospital, compulsory order)

Depot

Medication given by injection

Dynamic factors

Factors that can change

EPSE

(Extra-pyramidal) side effects

ETOH

Alcohol

FTD

Formal Thought Disorder

HMO

Hospital medical officer (who may be the person’s treating doctor, under supervision of the authorised psychiatrist)

H/O

History of

Hx

History

IMI

Intra-muscular injection (also known as ‘depot’)

MDE

Major depressive episode

MSE

Mental state examination (including assessment of appearance, mood, thought content, behaviour, insight and judgement, and overall demeanour)

MST

Mobile support team

Mx

Medication

NAD

No abnormality detected / No acute distress

OOB

Out of bed

PARC

Prevention and recovery centre – residential unit in the community for short-term treatment – often a step-down from hospital

PRN

‘as needed’ (as distinct from a regular dose of medication)

Protective factors

Things which can reduce the likelihood of a negative outcome, e.g. by reducing risk

RPN

Registered psychiatric nurse

SAD

Schizoaffective disorder

SECU

Secure extended care unit – locked mental health inpatient unit which provides rehabilitation and treatment, often long-term

SI/SH

Suicidal idealation/suicidal harm

SRS

Supported residential service

Static factors

Factors that do not change

TDS

Three times daily (medication frequency)

THC

Cannabis/marijuana

Tx / Rx

Treatment

UDS

Urine drug screen

Ψ

Psychiatrist/psychiatric

Ψ Reg

Psychiatric registrar

1/51, 2/52

Weekly, fortnightly

1/12, 2/12

Monthly, bi-monthly (every two months)

15/60, 60/60

Every 15 minutes, every hour (usually a reference to frequency of nursing observations required whilst an inpatient on the ward)

Also be aware of HoNOS – the Health of the Nation Outcome Scales, which cover a range of domains including psychiatric symptoms and relationships, and set out a series of scales, with the format:

0 = no problem
1 = minor problem requiring no action
2 = mild problem but definitely present
3 = moderately severe problem
4 = severe to very severe problem

Was this helpful?