While patient treatment records are important for good patient treatment and follow-up, records are also legal documents, so abbreviations and their meanings must be the same in all records. To make sure everyone in the office uses the same abbreviations and understands what the abbreviations mean, it's a good idea to create a “key” for the abbreviations used in your office so that anyone who writes or reads a record can understand exactly what is being transmitted. A good idea is to publish a “key” abbreviation where all employees can see it to help ensure that all of their records contain consistent and accurate information. The key will help all employees, past, present and future, as well as to be part of the legal record.
Annes — Anesthetic (e.g. From the Latin word “cum CAL” - Clinical insertion level CHD - Congestive heart disease CHF - Congestive heart failure COPD - Chronic obstructive pulmonary disease AVC - Cerebral vascular accident (stroke) DH - Dental hygienist or dental hygiene ECG or EKG - EEG electrocardiogram - Extraoral intraoral examination ER o DE - Emergency Room or Emergency Department FEN-Phen - Fenfluramine and Phentermine FMR, FMX (outdated), FMS - Full-mouth X-rays FPD - Fixed partial prosthesis; an HIV bridge - Human immunodeficiency virus IDDM - Insulin-dependent diabetes mellitus. Type I is the current preferred term Inc — Incisal, incisor, incisor LL — Lower left quadrant. Also called quadrant 3 Loc — local, localized and local anesthetic LR — lower right quadrant.
Also called Quadrant 4 MI — Myocardial infarction (heart attack) MRI — Magnetic resonance imaging MSA — Upper middle alveolar injection. NIDDM: non-insulin-dependent diabetes mellitus. Type II is the current preferred term OHI — Oral hygiene instructions ENT — Otolaryngology or otolaryngology. Refers to the head and neck area.
OTC - Over-the-counter (medicine obtainable without a prescription) Periodontal, periodontitis PFM - Metal-fused porcelain PMT, PMTx - Periodontal maintenance therapy or PPE treatment: personal protective equipment such as gloves, mask, gown and eye protection PRN, prn - As needed; as needed PSA — Superior posterior alveolar injection PSR — Quad or Q periodontal detection and recording — Quadrant. Can be followed by a number to specify a particular quadrant. RCTx or RCT — Root Canal Treatment Reevaluation, Disclosure — Reevaluation, Reevaluation of RHD — Rheumatic Heart Disease RPD — Removable Partial Denture S — No. From the Latin word “sine SBE” — Subacute bacterial endocarditis.
The preferred abbreviation and term are IE: Infectious Endocarditis (STD) - Sexually Transmitted Disease. The preferred abbreviation and term are STIs - Sexually Transmitted Infection (TMD) - Temporomandibular Joint (TMJ) Dysfunction or Disorder - Temporomandibular Joint URI - Upper Respiratory Tract Infection (UTI): Urinary Tract Infection Your session is about to expire. Do you want to continue with the logged in?. The medical community often uses abbreviations for commonly used words, phrases, ailments, and body parts.
The dental field is no exception. Taking abbreviated notes saves time and allows for better patient-doctor interaction. It also reduces the size of patient files to make it easier to transport from one visit to another. As a patient or student, it is helpful to keep abreast of these dental abbreviations yourself.
Keep this list handy every time you find a dental history or file. Specialized dentists, such as orthodontists (whom you may know better as dentists who help align teeth with braces and other products) or periodontists (who specialize in gum and bone disease), should be able to read notes left in medical records left by the primary dental provider. Knowing the abbreviations commonly used in the dental community can benefit doctors, patients, nurses and dental students alike. Having a list of abbreviations can help patients and doctors find alternative treatments or more information about problems.
Patients can also review their medical records and understand the various annotations if they have a list of abbreviations available. If you are looking for a dentist, you may notice that while most appear with a “DDS”, some may appear as “DMD”. Both mean the same thing that your dentist graduated from an accredited dental school. The DDS (Doctor of Dental Surgery) and the DMD (Doctor of Medicine in Dentistry or Doctor of Dental Medicine) are the same degrees.
Dentists who have a DMD or DDS have the same education. It is up to universities to determine which degree is awarded, but both degrees use the same curricular requirements. With this in mind, and in an effort to spread uniformity to authors, educators, practitioners, oral health care students, and others who need to know abbreviations, symbols, and acronyms related to dentistry, the ADA has compiled a list, reflecting current common usage. Some groups, such as the Army or even offices within insurance groups, may also maintain their own lists of acronyms and abbreviations.
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