Common Abbreviations in Medical Notes

If you'd like to support us, check out our awesome products:

📖 Geeky Medics OSCE Book
⚡ Geeky Medics Bundles
✨ 1300+ OSCE Stations
✅ OSCE Checklist PDF Booklet
🧠 UKMLA AKT Question Bank
💊 PSA Question Bank
💉 Clinical Skills App
🗂️ Flashcard Collections | OSCE, Medicine, Surgery, Anatomy
💬 SCA Cases for MRCGP

To be the first to know about our latest videos subscribe to our YouTube channel 🙌

Introduction

Abbreviations and acronyms are commonly used in medical notes. If you are unfamiliar with common abbreviations, it can make understanding medical notes challenging. We’ve curated a list of medical abbreviations/acronyms to help you understand entries in the medical notes.

Remember, using ambiguous abbreviations increases the risk of miscommunication. Your hospital may have an approved list of abbreviations.

History

Structure of the medical history

Abbreviation	Meaning
PC	Presenting complaint
HPC	History of presenting complaint
PMH/PMHx	Past medical history
SR	Systems review
DH/DHx	Drug history
FH/FHx	Family history
SH/SHx	Social history
LMP	Last menstrual period
h/o	History of
c	With Usually has a line over the c
^Ø	No/none Usually written before a symptom (e.g. ^ØChest pain = No chest pain)
ADLs	Activities of daily living

Timing

Number of days = number of days/7 (e.g. 3/7 = 3 days)
Number of weeks = number of weeks/52 (e.g. 4/52 = 4 weeks)
Number of hours = Xº (e.g. 8º = 8 hours)

Medical conditions and procedures

While care should always be taken when using acronyms in notes, it is particularly important for medical conditions, as the same acronym can mean different conditions depending on the specialty.

Abbreviation	Meaning
AAA	Abdominal aortic aneurysm
ACS	Acute coronary syndrome
AF	Atrial fibrillation
AKI	Acute kidney injury
ASD	Atrial septal defect
BCC	Basal cell carcinoma
BPH	Benign prostatic hyperplasia
CABG	Coronary artery bypass graft
CAD	Coronary artery disease
COPD	Chronic obstructive pulmonary disease
CF	Cystic fibrosis
CKD	Chronic kidney disease
DVT	Deep vein thrombosis
ESRD/ESRF	End-stage renal disease/End-stage renal failure
GORD	Gastro-oesophageal reflux disease
HOCM	Hypertrophic obstructive cardiomyopathy
IBD	Inflammatory bowel disease
IBS	Irritable bowel syndrome
MI	Myocardial infarction
MM	Multiple myeloma
MS	Multiple sclerosis
NSTEMI	Non ST-segment elevation myocardial infarction
OA	Osteoarthritis
OGD	Oesophagogastro duodenoscopy
ORIF	Open reduction internal fixation
PAD	Peripheral arterial disease
PE	Pulmonary embolism
PID	Pelvic inflammatory disease
PCOS	Polycystic ovarian syndrome
RA	Rheumatoid arthritis
SCC	Squamous cell carcinoma
SLE	Systemic lupus erythematosus
STEMI	ST-segment elevation myocardial infarction
STI	Sexually transmitted infection
UC	Ulcerative colitis
UTI	Urinary tract infection
VSD	Ventricular septal defect

You might also be interested in our premium collection of 1,300+ ready-made OSCE Stations, including a range of documentation stations ✨

Medications

Abbreviation	Meaning
OD	Once daily
BD	Twice daily
TDS	Three times daily
QDS	Four times daily
PRN	As required
SC	Subcutaneous
IM	Intramuscular
IV	Intravenous
Stat	Immediately
OTC	Over the counter
OM	“omni mane” – Every morning
ON	“omni nocte” – Every night
Neb	Nebulised

Examination

Abbreviation	Meaning
O/E	On examination
BP	Blood pressure
RR	Respiratory rate
Sats	Oxygen saturation
RA	Room air
I + II + 0	Heart sounds 1 and 2 heard, with no added sounds
BS	Bowel sounds
RUL/LUL	Right/left upper limb
RLL/LLL	Right/left lower limb
RUQ/LUQ	Right/left upper quadrant
RLQ/LLQ	Right/left lower quadrant
RIF/LIF	Right iliac fossa/left iliac fossa
CN	Cranial nerve
PEARL	Pupils equal and reactive to light
FROM	Full range of movement
NAD	Nothing abnormal detected/discovered Commonly used when documenting examination findings (e.g. “Abdominal exam NAD”)
SNT	Soft, non-tender Used in the context of documenting abdominal examination findings (e.g. “Abdo SNT”)
SLR	Straight leg raise
+ve / -ve	Positive / negative Commonly used to document examination findings (e.g. “FAST +ve”)
+	Present
++	Present significantly
+++	Present in excess

Investigations

Abbreviation	Meaning
ABG	Arterial blood gas
ANA	Antinuclear antibody
ANCA	Anti-neutrophil cytoplasmic antibody
BM	Capillary blood glucose (short for ‘Boehringer Mannheim’ – a manufacturer of blood glucose test strips)
CBG	Capillary blood glucose (for blood sugar) or capillary blood gas
CTA	CT angiography
CTG	Cardiotocograph
CT TAP/CT CAP	CT scan of the thorax/chest, abdomen and pelvis
CSF	Cerebrospinal fluid
CSU	Catheter specimen of urine
CXR	Chest X-ray
eGFR	Estimated glomerular filtration rate
ECG	Electrocardiogram
EEG	Electroencephalogram
ESR	Erythrocyte sedimentation rate
FBC	Full blood count
G+S/G&S	Group and save
LFTs	Liver function tests
L&S BP	Lying & standing blood pressure
INR	International normalised ratio
MRI	Magnetic resonance imaging
MRCP	Magnetic resonance cholangiopancreatography
MSU	Mid-stream urine sample
OGTT	Oral glucose tolerance test
PEFR	Peak expiratory flow rate
TFTs	Thyroid function tests
U&E	Urea and electrolytes
US/USS	Ultrasound/ultrasound scan
VBG	Venous blood gas
AXR	Abdominal X-ray
X-match	Crossmatch

Other abbreviations

Abbreviation	Meaning
1 ATD	Adult therapeutic dose >Used to refer to 1 unit/bag of platelets
AMHP	Approved mental health professional
ATSP	Asked to see patient Commonly used in on-call situations (e.g. “ATSP: reduced urine output”)
Auto/allo SCT	Autologous/allogenic stem cell transplant
BIBA	Brought in by ambulance Used in ED to indicate the patient was brought to the department by ambulance instead of via the waiting room.
BNO	Bowels not open(ed)
CPN	Community psychiatric nurse
DNACPR/DNR/DNAR	Do not attempt CPR/Do not resuscitate/Do not attempt resuscitation
Ddx	Differential diagnoses
DNA	Did not attend
DOLS	Deprivation of liberty safeguards
D&V	Diarrhoea & vomiting
EDD	Estimated date of discharge
EUA	Examination under anaesthesia
FAST	Face arms speech test
FFP	Fresh frozen plasma
GA	General anaesthetic
HAS	Human albumin solution
HCA	Healthcare assistant
HRT	Hormone replacement therapy
IVF	Intravenous fluids
IVI	Intravenous infusion
Ix	Investigations
LA	Local anaesthetic
LPA	Lasting power of attorney
MCA	Mental capacity act
MDT	Multidisciplinary team This could refer to the ward team (an MDT consisting of doctors, nursing staff, and allied health professionals) or a cancer MDT meeting (e.g., the upper GI MDT)
MFFD	Medically fit for discharge
MHA	Mental health act
MOCA	Montreal cognitive assessment
MRSA	Methicillin-resistant Staphylococcus aureus
NAI	Non-accidental injury
NBM	Nil by mouth
NEWS	National early warning score
NOF	Neck of femur fracture
#NOK	Next of kin
OT	Occupational therapist / occupational therapy
POA	Power of attorney
POC	Package of care
POP	Plaster of paris
PT	Physiotherapist/physiotherapy
PU	Passed urine
ROSC	Return of spontaneous circulation
SLT/SALT	Speech (and) language therapist
SOB(OE)	Shortness of breath (on exertion)
TCI	To come in Commonly used in patient lists to indicate which patients are on their way to hospital (e.g. following a GP referral)
TTO/TTA	To-take-out/To-take-away This refers to medications the patient is discharged with
VTE	Venous thromboembolism
#	Fracture
ΔΔ	Used to indicate differential diagnoses
Δ	Used to indicate the current diagnosis