Victoria Legal Aid

Common terms and abbreviations in clinical files

A list of common terms and abbreviations that might be contained in clinical files.

Term/abbreviation Meaning
ABI Acquired brain njury
ADLs Activities of daily living (e.g. dressing, showering, eating, cooking etc)
AOD Alcohol or other drugs
AH Auditory hallucinations
AMA Acute management area (another term for HDU)
ANUM Associate nurse unit manager
Ax Assessment
BD Twice daily (medication frequency)
BIBA Brought in by Ambulance
BIBP/F Brought in by police/family
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 (anti-psychotic medication)
COS Close of shift
CRCU Community Residential Care Unit
CTT Continuing care team (based at a community mental health service)
CWM/CWT Compliant with medication/compliant with treatment
D&A Drugs and alcohol
D/C Discharge (from hospital, compulsory order)
Depot Medication given by injection
Dx Diagnosis
Dynamic factors Factors that can change
ECU Extended care unit
ED Emergency Department
EL / UEL Escorted Leave / Unescorted Leave
EPSE (Extra-pyramidal) side effects
ETOH Alcohol
Fa Father
FEP First episode psychosis
Flexicare Another term for a high dependency or intensive care unit
FTD Formal Thought Disorder
Gfa Grandfather
Gmo Grandmother
HDU/HDAU High dependency unit/ High dependency acute unit (usually a separate area of an acute unit with higher staff/patient ratios and lower stimulus)
HTO/TOHTO Harm to others/thoughts of harm to others
HMO Hospital medical officer (who may be the person’s treating doctor, under supervision of the authorised psychiatrist)
H/O History of
Hx History
ICA Intensive care area (another term for HDU)
ID Intellectual disability
IR Immediate release (medication)
IM/IMI Intra-muscular injection (also known as ‘depot’)
IVDU Intravenous drug use
LDU Low dependency unit
Mane Morning (refers to administration of medication)
MDE Major depressive episode
Mo Mother
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
NaVa Sodium Valproate
Nil FTD No formal thought disorder
Nil PD No perceptual Disturbances
Nocte Nightly (refers to administration of medication)
NUM Nurse Unit Manager
OOB Out of bed
PARC Prevention and recovery centre – residential unit in the community for short-term treatment – often a step-down from hospital
PO Per oral/orally
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

Q1h/Q1w/Q1m Every hour/every week/every month
RIB Resting in bed
RPN Registered psychiatric nurse
Rx Medical prescription
SAD Schizoaffective disorder
Schx / Sz Schizophrenia
SECU Secure extended care unit – locked mental health inpatient unit which provides rehabilitation and treatment, often long-term
SI/SH/HTO/TOSHSI Suicidal ideation/self-harm/harm to others/thoughts of self-harm and suicide
Sn Seclusion
SRS Supported residential service
Sx Symptoms
Static factors Factors that do not change
TDS Three times daily (medication frequency)
THC Cannabis/marijuana
Tx Treatment
UEL / EL Unescorted leave / escorted leave
UDS Urine drug screen
VH Visual hallucinations
XR Extended release (medications)
++, +++ Very (e.g. aggression+++)
Ψ Psychiatrist/psychiatric
Ψ Reg Psychiatric registrar
1/52, 2/52 Weekly, twice a week
1/26 Fortnightly
3/7 ago, 3/52 ago 3 days ago, 3 weeks ago
1/12, 2/12 Monthly, twice a month
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

Disclaimer: The material in this print-out relates to the law as it applies in the state of Victoria. It is intended as a general guide only. Readers should not act on the basis of any material in this print-out without getting legal advice about their own particular situations. Victoria Legal Aid disclaims any liability howsoever caused to any person in respect of any action taken in reliance on the contents of the publication.

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Reviewed 24 March 2022

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