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