Here are some common medical terms and abbreviations that may appear in your records. You can search within the page (Control + F on a computer) or use the index below to navigate.
c̅ (letter C with a line over it): with
CFS: contract for safety, sometimes called a "no-suicide contract" or NSC. If a person contracts for safety it means they have agreed verbally or in writing not to harm themselves.
c/o: complains of, complaint of
DC, D/C: discharge (as in being discharged from a hospital)
denies: answers no, or states that something is not present
▸ Note: in medical records, "deny" is a standard term that does not have a negative connotation. A sentence like "Patient denies alcohol use" means that your provider asked if you use alcohol, and you said no. It does not mean that they think you are lying or "in denial."
DOB: date of birth
DDx: dual diagnosis (typically means diagnosis of a mental illness plus substance abuse)
▸ Note: in medical records, "complain" and "complaint" are standard terms that don't have negative connotations. A sentence like "Patient complains of stomach pain" means that you told your provider that you have stomach pain, not that they think you are whining about it.
f/u: follow up
MRN: medical record number
Rx: prescription, prescribe
△ (triangle): change
Agencies and Facilities
These will be different in different areas, but the ones on this list are common or general names
APS: Adult Protective Services
BnC, B&C, B & C: board and care
CMH: County Mental Health
DMH: Department of Mental Health
DPH: Department of Public Health
CPS: Child Protective Services
P&A, P & A: Protection and Advocacy, a type of state agency that advocates for the rights of people with disabilities
PES: Psychiatric Emergency Services
SNF: skilled nursing facility (nursing home)
affect: in this context, affect is a provider's perception of a patient's overall demeanor and outward emotional expression. Common words used to describe affect:
- flat, flattened, restricted, limited, blunted: little or no outward expression of emotion
- labile: changing very quickly, such as quickly going from crying to laughing
- broad: able to express broad range of emotions in a way considered "normal" or "healthy"
BP: blood pressure
ADL, ADLs: Activities of Daily Living, a term that refers to daily tasks such as getting dressed, feeding yourself, preparing meals, and hygiene.
WNL: within normal limits
MMPI: Minnesota Multiphasic Personality Inventory, an extensive personality-testing instrument
MDQ: Mood Disorder Questionnaire, a screening instrument for bipolar disorders.
Y-BOCS: Yale-Brown Obsessive Compulsive Scale, a diagnostic instrument for OCD.
"No SI/HI/CFS": no suicidal ideation, no homicidal ideation, contracts for safety.
DSM: Diagnostic and Statistical Manual of Mental Disorders, the authoritative book of mental health diagnoses in the U.S. that describes the criteria for assigning specific diagnoses. It is published by the American Psychiatric Association.
▸ You may also see references to specific editions, such as DSM-I (1952-1968), DSM-II (1968-1980), DSM-III (1980-1994), DSM-IV (published in 1994, still in use), or DSM-V (published in 2013, currently adopted by some providers but not others).
Axis I, Axis II, Axis III, Axis IV, Axis V: The 5-axis system is a system of organizing diagnoses. It comes from the DSM and is often required for insurance purposes.
- Axis I: "primary" mental illness diagnosis
- Axis II: personality disorders; developmental disabilities
- Axis III: physical medical conditions, especially if relevant to mental state
- Axis IV: "psychosocial stressors," or life circumstances affecting mental state, such as homelessness, job loss, divorce.
- Axis V: "Global Assessment of Functioning," sometimes abbreviated GAF. A number between 1-100 that is intended to describe a person's overall "functioning," with 100 being best and 1 being worst. Here is a detailed GAF chart (PDF) with more information.
ICD-10: International Statistical Classification of Diseases and Related Health Problems, 10th edition. An international diagnostic manual published by the World Health Organization.
NOS: Not Otherwise Specified
Drugs and alcohol
AOD: alcohol and other drugs
MMJ: medical marijuana
MMT: methadone maintanence therapy, methadone maintanence treatment
SA: substance abuse
W/D, WD: withdrawals
These can differ by state or area. Specific locations are indicated where necessary.
5150: involuntary 72-hour hold in California
5250: involuntary 14-day hold in California
5270: involuntary 30-day hold in California
Baker Act: Florida law on involuntary commitment/72-hour hold
conservatorship: a legal status that gives another person (the conservator) the power to make legal, medical and/or financial
decisions for a person considered "gravely disabled" or unable to care for themselves.
grave disability: specific legal definitions vary by state, but generally means a person is considered unable to care for themselves. This is the basis for conservatorship, and can also be used to justify an involuntary hold even if someone is not going to actively harm themselves or others. Sometimes applied when a person is not eating.
LPS: Lanterman-Petris-Short act in California, a law that regulates involuntary commitment and conservatorship.
T-Con: informal abbreviation for "temporary conservatorship."
BID: twice a day
IM: intramuscular, into the muscle (usually describes an injection-- for example, "IM lorazepam" is lorazepam injected into a muscle)
QAM: every morning
PRN: as needed
People and certifications
ASW: Associate Clinical Social Worker
CNA: certified nursing assistant
LCSW: Licensed Clinical Social Worker
LVN: licensed vocational nurse
LPCC: Licensed Professional Clinical Counselor
LPN: licensed practical nurse
LPT: Licensed Psychiatric Technician
MD: medical doctor
MFT: Marriage and Family Therapist
MFTi: Marriage and Family Therapist intern
MSW: master's degree in social work
NP: Nurse Practitioner
Psy.D: doctorate degree in psychology
RN: registered nurse
AH: auditory hallucinations (hearing voices or other sounds that other people don't hear). Also sometimes written as "audio hallucinations."
BFRB: body-focused repetitive behavior, such as picking at skin or pulling hair out
CAH: command auditory hallucinations (hearing voices that tell you to do something)
HI: homicidal ideation (thoughts of killing another person)
SI: suicidal ideation (thoughts of killing yourself) (also sometimes stands for self-injury)
S/I: self-injury (also sometimes written SI, without slash). Also sometimes called NSSI (non-suicidal self-injury), SIB, SIBs (self-injurous behavior/s), or S/H, SH (self-harm).
VH: visual hallucinations (seeing things that other people don't see)
ABA: Applied Behavior Analysis
CBT: Cognitive Behavioral Therapy
DBT: Dialectical Behavioral Therapy
DBS: Deep Brain Stimulation
ECT: Electroconvulsive Therapy (formerly called electroshock)