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A |
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A- Assistance |
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A&E - Accident and Emergency |
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A/L - Annual Leave |
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A/P- Attendant Propel |
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A/w - Admitted with |
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AA - Aortic aneurysm |
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AAA – Abdominal Aortic Aneurysm AAROM - Active Assisted Range of Movement |
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Abdo- Abdominal |
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ABG- Arterial Blood Gas |
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ABI – Acquired Brain Injury |
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Abx – Antibiotics ACE - Addenbrookes Cognitive Examination ACIS- Assessment of Communication and Interaction Skills |
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ACP - Advanced Clinical Practitioner |
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ACS - Acute Coronary Syndrome ACT - Acceptance and Commitment Therapy AD- Anti depressants |
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ADHD - Attention Deficit Hyperactivity Disorder |
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ADLs - Activities of Daily Living |
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AF - Atrial Fibrillation |
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AFO- Anterior Foot Orthosis |
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AKA - Above Knee Amputation |
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AKI – Acute Kidney Injury |
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ALD - Adults with Learning Disability |
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AM – Morning |
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AMH- Adult Mental Health |
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AML - Acute Myeloid Leukaemia |
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AMU – Acute Medical Unit |
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ANP – Advanced Nurse Practitioner |
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AP – Advanced Practitioner |
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Apt / Appt – Appointment AROM - Active Range of Movement |
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AS - Aortic Stenosis |
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ASAP - As Soon As Possible |
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ASD/ASC - Autism Spectrum Disorder / Autism Spectrum Condition |
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AusTOMs –Australian Therapy Outcome Measure Ax - Assessment |
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B |
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B/K - Below Knee |
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B/L- Bilateral/ Bed Lever (contextual) |
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BAOT- British Association of Occupational Therapists |
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BB- Bathboard |
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BCUHB - Betsi Cadwaladr University Health Board |
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Bd - Twice a day |
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BI - Best Interests |
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BIBA - Brought In By Ambulance |
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BIM - Best Interests Meeting |
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BKA - Below Knee Amputation |
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BMI – Body Mass Index |
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BNO – Bowels Not Opened |
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BO – Bowels Opened |
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BP - Blood Pressure BPD- Borderline Personality Disorder BPSD- Behavioural and Psychological Symptoms of Dementia BPPV – Benign Postural Paroxysmal Vertigo |
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Bx – Biopsy |
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BYN – Bryn Y Neuadd |
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C |
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c/o - complains of |
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C19 – COVID 19 / coronavirus |
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Ca - Cancer |
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CA - Chronological Age |
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CABG - Coronary Artery Bypass Grafting |
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CAMHS - Child and Adolescent Mental Health Services |
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CAP - Community Acquired Pneumonia |
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CBCH – Colwyn Bay Community Hospital |
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CBT - Cognitive Behavioural Therapy |
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CC- Case Conference |
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CCF - Congestive Cardiac Failure |
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CCH- Chirk Community Hospital |
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CCU - Coronary Care Unit |
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CHC- Continuing Health Care |
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Chemo – chemotherapy |
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CI – Cochlear Implant |
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CLBP - Chronic Low Back Pain |
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CLDN - Community learning Disability nurse |
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CLDT – Community Learning Disability Team |
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CLL - Chronic Lymphatic Leukaemia CMCJ- Carpal Meta Carpal Joint |
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CMHT - Community Mental Health Team |
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CNA - Could not attend |
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CNS - Central Nervous System (contextual) |
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CNS – Clinical Nurse Specialist |
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COCH - Countess of Chester Hospital |
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Cons - Consultant |
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Cont. - Continued |
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COPD - Chronic Obstructive Pulmonary Disease |
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COPM- Canadian Occupational Performance Measure |
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COTE - Care Of the Elderly |
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CP - Cerebral Palsy |
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CPAP – Continuous Positive Airway Pressure |
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CPN - Community Psychiatric Nurse |
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CPR - Cardio Pulmonary Resuscitation |
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CR- Cardiac Rehabilitation |
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CRF - Chronic Renal Failure |
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CRT- Community Resource Team |
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CS - clinical supervisor |
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CSF - Cerebral Spinal Fluid |
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CT - Computed Tomography |
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CTC – Cancer Treatment Centre CTO- Community Treatment Order CTP- Care and Treatment Plan |
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CTR - Carpal Tunnel Release |
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CTS - Carpal Tunnel Syndrome |
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CTX - Chemotherapy |
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CVA - Cerebrovascular Accident |
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CVS - Cardiovascular System |
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CXR - Chest X-Ray |
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D |
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D/C - Discharge |
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D/W - Discussed With |
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DA- Dressing Aids |
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DADL- Domestic Activities of Daily Living |
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DATIX – BCUHB Incident Report |
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DCH- Deeside Community Hospital |
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Dept- Department |
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DHS - Dynamic Hip Screw |
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DI – Denbigh Infirmary Hospital |
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DIPJ- Distal Interphalangeal Joint |
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DLA- Disability Living Allowance |
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DMD - Duchene’s Muscular Dystrophy |
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DN - District Nurse |
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DNA - Did Not Attend |
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DNACPR - Do Not Attempt Cardio Pulmonary resuscitation |
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DNR - Do not resuscitate |
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DOB - Date of Birth |
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DOD- Date of Discharge/ Date of Death (contextual) |
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DOI - Date of Injury |
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DOLS – Deprivation of Liberty Safeguards |
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DOSA – Day of Surgical Arrivals |
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Dr or DR – Doctor DSH- Deliberate Self Harm |
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DT - Dietitian |
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DV or domi – Domiciliary Visit |
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DVT - deep vein thrombosis |
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DXT – Radiotherapy |
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E |
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EA - Emergency Admission |
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EAT – Electronic Assistive Team |
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ECG – Electrocardiogram ECHO – Echocardiogram ECT- Electro Convulsive Therapy |
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ED - Emergency Department |
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EEG - Electroencephalogram EFRS- Enhanced Falls Response Service |
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EMG -Electro myelogram |
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EMI - Elderly mental Illness |
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ENT - Ear, Nose and Throat |
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EOL – End of Life EPP- Education Programme for Patients |
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EUA - Examination Under Anaesthetic EV - Environmental Visit EUPD- Emotionally Unstable Personality Disorder |
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F |
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F – Female F2F- Face to Face |
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FBC - Full Blood Count |
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Fe - Iron |
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FH - Family History |
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FMS - Fine Motor Skills FRSM – Fluid repellent surgical Mask |
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FSTF- Free Standing Toilet Frame |
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FTD – Frontal temporal Dementia |
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FTM – Female to male |
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FUHV- Follow Up Home Visit |
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FUTC- Follow Up Telephone Call |
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FWB - Fully Weight Bearing |
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FY1 / FY2 – Foundation Doctor |
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G |
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GA - General Anaesthetic GAD- Generalised Anxiety Disorder GAD7- Generalised Anxiety Disorder 7 assessment |
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GBS – Guillain-Barre Syndrome |
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GCS - Glasgow Coma Scale |
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GD – Gender Dysphoria |
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GI – Gender Identity |
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GIC – Gender Identity Clinic |
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GMS - Gross Motor Skills |
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GORD – Gastroesophageal Reflux Disease |
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GP - General Practitioner |
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GR- Grab Rail |
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GRS – Gender Reassignment Surgery |
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GU - Genitourinary |
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H |
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H&N – Head & Neck |
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H/H- Helping Hand |
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h/o - History of |
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HADS – Hospital Anxiety & Depression Scale |
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HAP – Hospital Acquired Pneumonia |
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Hb – Haemoglobin |
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HCA - Health care Assistant |
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HCH – Holywell Community Hospital |
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HCSW - Health Care Support Worker |
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HD – Huntington’s Disease |
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HDU - High Dependency Unit |
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HHA- Hand Held Assistance |
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HI - Head Injury – Hearing Impaired |
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HOF - Head of Femur |
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HPC - History of Presenting Complaint |
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HTN - Hypertension |
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HV - Health Visitor/ Home Visit contextual |
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Hx – History |
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I |
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I- Independent |
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ICD - international Classification of Disorders ICH - Intracerebral Haemorrhage |
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ICU - Intensive Care Unit |
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IDDM - Insulin Dependent Diabetes Mellitus |
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IEP - Individualised Education programme |
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IHD - Ischaemic Heart Disease |
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II- Initial Interview |
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IM- Intra-muscular |
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Info- Information |
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IP- Inpatient |
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ITU- Intensive Therapy Unit |
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IV- Intravenous |
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IVABX - Intravenous Antibiotics |
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IVI - Intravenous Infusion |
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J |
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K |
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K - Potassium |
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KA- Kitchen Assessment |
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KT- Kitchen Trolley |
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L |
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L - Left |
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L/L - Lower Limb |
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LA – Local Anaesthetic/ Local Authority (contextual) |
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LACLS – Large Allen Cognitive Level Screen |
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LBP- Lower Back Pain |
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LD - Learning disability |
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LFT - Lung Function Test / Liver function test / Lateral Flow Test (contextual) |
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LGT – Local Gender Team |
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LHCH – Liverpool Heart and Chest Hospital |
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LHS- Left Hand Side |
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LHSH- Long Handled Shoe Horn |
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LIF - Left Iliac Fossa |
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LL- Leg Lifter |
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LLGH – Llandudno General Hospital |
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LP – Lumbar Puncture |
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LPA – Lasting Power of Attorney |
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LRTI - Lower Respiratory tract Infection |
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LTM- Long Term Memory |
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LVF - Left Ventricular Failure |
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Lx – Laryngeal |
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M |
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M – Male |
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Max- Maximum |
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MCA – Mental Capacity Act / Middle Cerebral Artery (contextual) |
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MCH- Mold Community Hospital MCPJ- Meta-Carpal Interphalangeal Joint |
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MD - Muscular Dystrophy |
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MDT - Multi Disciplinary team |
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MDU – Medical Day Unit |
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Mets - Metastases |
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MFFD - Medically fit for discharge |
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Mg - Magnesium |
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MH - Medical History / Mental health/ Manual Handling (contextual) MHA- Mental Health Act MHM- Mental Health Measure |
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MI - Myocardial Infarction |
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MID - Multi Infarct Dementia |
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Min- Minimum |
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MND - Motor Neurone Disease |
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Mob- Mobilised/ Mobility MOHO- Model of Human Occupation MOHOST- Model of Human Occupation Screening Tool MOCA - Montreal Cognitive Assessment |
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MR - Mitral Regurgitation |
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MRI - Magnetic Resonance Imaging |
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MRSA +ve/-ve - Methicillin Resistant Staphylococcus Aureus |
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MS - Multiple Sclerosis MSE- Mental State Examination MSC- Motor, Sensation, Circulation |
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MSU- Mid Stream Urine |
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MTD – Muscle Tension Dysphonia |
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MTF – Male to Female |
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MUA- Manipulation Under Anaesthetic |
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N |
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N/A - Not Applicable |
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NAD - No Abnormalities Detected |
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NBM – Nil By Mouth |
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NC – Nasal cannula |
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ND - Normal diet |
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NDF - Normal diet and fluids |
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Nebs- Nebuliser NERS- National Exercise Referral Scheme |
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NEWCES- North East Wales Community Equipment Service |
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NEWCIS – North East Wales Carers Information Service |
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NG tube / NGT – Nasogastric Tube |
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NH - Nursing Home |
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NHF – Nasal high flow |
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NICE - National Institute for Clinical Excellence |
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NIDDM - Non Insulin Dependent Diabetes Mellitus |
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NIV – Non-Invasive Ventilation NMFD – Not medically fit for discharge |
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NOF - Neck of Femur |
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NOH - Neck of Humerus |
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NOK - Next of Kin |
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NST – Nutritional Support Team |
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NSTEMI- Non ST Elevation Myocardial Infarction |
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NWB - Non Weight Bearing |
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NWBIS – North Wales Brain Injury Service |
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NWCTC – North Wales Cancer Treatment Centre |
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O |
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O/E - On Examination |
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O2 - Oxygen |
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OA - Osteoarthritis |
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OBS- Over Bath Shower/ Observations (contextual) |
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OBT- Over Bed Table OCAIRS- Occupational Circumstances Assessment Interview Rating Scale OD- Overdose OCS - Oxford Cognitive Assessment |
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OGD - Oesophago – gastro – duodenoscopy |
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OM – Outcome Measures |
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OO- Owner Occupied |
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Op - Operation |
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OP - Out patient |
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OPD - Out Patient Department |
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OPMH – Older Person’s Mental Health OSA- Occupational Self-Assessment OSA-SF- Occupational Self-Assessment Short Form |
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OT - Occupational Therapy OTAP – Occupational Therapy Assistant Practitioner |
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OT TI - Occupational Therapy Technical Instructor |
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OTS- Occupational Therapy Student |
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P |
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P/C - Presenting Complaint |
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P/S- Perching Stool |
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PA - Personal Assistant |
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PACS - Partial Anterior Circulation Stroke PADLS - Personal Activities of daily Living |
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PAEDs – Paediatrics PAL- Pool Activity Level assessment PAMS- Posture and Mobility Service PC- Primary Care PCP – Person Centred Planning PD - Parkinson’s Disease PE - Pulmonary Embolism PEG - Percutaneous Endoscopic Gastrostomy PHQ 9 - Patient Health Questionnaire Physio/ PT- Physiotherapist PIP- Personal Independence Payment PIPJ- Proximal Interphalangeal Joint PM – Afternoon PMH- Past Medical History PMHP - Perinatal Mental Health Practitioner PMHT - Perinatal Mental Health Team PMLD- Profound and Multiple Learning Disability POA - Plan of Action POC - Package of care POCS- Posterior Circulation Stroke POP- Plaster of Paris PORT- Pulmonary Outreach Team PPE - Personal protective Equipment PPI – Proton Pump Inhibitor PR- Pulmonary Rehabilitation Pre OP - Pre Operatively PREMS – Patient Reported Experience Measures PRN - As necessary |
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PROM - Passive Range of Movement / Patient Reported Outcome Measures (contextual) PROP - Proprioceptive PSP - Progressive Supranuclear Palsy Pt- Patient PTA - Post Traumatic Amnesia PTSD - Post Traumatic Stress Disorder PU - Passed Urine PVD - Peripheral Vascular Disease PWB - Partial Weight Bearing |
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Q QD / QDS - 4 times a day QOL – Quality Of Life
R R - Right R/R- Rise Recliner Chair R/V - Review RA - Rheumatoid Arthritis/ Risk Assessment (contextual) RAH – Royal Alexandra Hospital RCH – Ruthin Community Hospital RCOT- Royal College of Occupational Therapists RCP - Royal College of Physicians Re - Regarding Recs - Recommendations Ref – Referring to / reference to / referral Reg. – Registrar Rehab- Rehabilitation REIS – Residential Environment Impact Scale Resp – Respiratory RGN - Registered General Nurse RH - Residential Home RHS- Right Hand Side RIG – Radiologically Inserted Gastrostomy RIP - Rest in Peace RMN- Registered Mental Health Nurse RN- Registered Nurse RNLD – Registered Nurse for people with a Learning Disability ROM - Range of Movement RS - Respiratory System RSI - Repetitive Strain Injury RTA - Road Traffic Accident RTS- Raised Toilet Seat RVF - Right Ventricular Failure Rx – Treatment RxT - Radiotherapy
S S/b or SB - Seen by S/L - Sick Leave S/P- Self Propel S/S- Social Services SA- Sock Aid SAH - Sub-arachnoid Haemorrhage SALT/ SLT - Speech and Language Therapy/Therapist SBAR - Situation Background Assessment Recommendations (Plan) SCC - Spinal Cord Compression SDEC – Same Day Emergency Care SDH - Subdural Haematoma SH - Social History SHO - Senior House Officer SN - Staff Nurse SOAP- Subjective, Objective, Analysis, Plan SOB - Short of Breath SOBOE - Short of Breath on Exertion SOEOB- Sit on Edge of Bed SOL - Space Occupying Lesion SpR – Specialist Registrar SPoAA- Single Point of Assessment and Allocation SPOC- Single Point of Contact SR - Sinus Rhythm STM- Short Term Memory STML- Short Term Memory Loss STS- Sit to Stand SU – service user SVT- Supra Ventricular Tachycardia SW - Social Work/er SWMS - Specialist Weight Management Service Sx- Surgery / surgery assessment
T T/C or Tel - Telephone Call TA- Tights Aid TACI – Total Anterior Circulation Infarct TACS - Total Anterior Circulation Stroke TB- Tuberculosis TBA – To be arranged TBC – To be confirmed TC – Treatment Complete TCI - To Come In TDS - 3 Times a day Temp- Temperature TF – Transfer TFLS – The Functional Living Scale TG - Transgender THR - Total Hip Replacement TI - Technical Instructor TIA - Transient Ischaemic Attack TKR - Total Knee Replacement TLC - Tender Loving Care TM - Therapy Manager TMJ – Temporamandibular Joint TNM – Tumour Node Metastases TOC – Transfer of care TOMs – Therapy Outcome Measures TTO’s - Tablets to Take Out TTWB – Toe touch weight bearing TURP - Transurethral Resection of Prostrate TWOC - Trial without Catheter Tx – Treatment / Therapy
U U&E’s - Urea and Electolytes U/L - Upper Limb URT - Upper Respiratory Tract URTI – Upper Respiratory Tract Infection USS - Ultra Sound Scan UTA - Unable to Attend UTI - Urinary Tract Infection
V VC – Video Call VEST - Vestibular VF - Ventricular Fibrillation VP - Visual Perception VQ- Volitional Questionnaire VR - Vocational Rehabilitation VT- Ventricular Tachycardia
W W&D- Washing and Dressing Assessment W/c - week commencing W/C - Wheelchair W/S- Walking Stick WAST- Welsh Ambulance Service Trust WB - Weight Bearing WBC - White Blood Corpuscle WCC- White Cell Count WEIS - Work Environment Impact Scale WGS – Welsh Gender Service WLS – Weight Loss Surgery WMH - Wrexham Maelor Hospital WPAS – Welsh Patient Administration System WR - Ward Round WZF- Wheeled Zimmer Frame WMS – Weight Management Service
X x- Times XRT – Radiotherapy
Y YG - Ysbyty Gwynedd YGC - Ysbyty Glan Clwyd YM – Ysbyty Maelor Yrs- Years
Z ZF - Zimmer Frame
Symbol use and numerical: < Increase > Decrease ? – used to signify a query / uncertainty # - Fracture ++ - use to exemplify the severity level. (A lot of) 1:1 - one to one 1/7 -one day; 2/7 two days etc. 1/52 - One Week; 2/52 two weeks etc. 1/12 - One Month; 8/12 eight months etc.
Accepted staff initials used in context: OT staff initials can be used but contextualised, e.g. d/w OT AA
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