Common Abbreviations in Medical Notes

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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.Β 

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


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 = XΒΊ (e.g. 8ΒΊ = 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
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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
Ξ” Used to indicate the current diagnosis

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