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Medical Abbreviations in the Health Record

Updated on July 14, 2016
PatriciaJoy profile image

PatriciaJoy has been working at home in the medical transcription field since 2005 and loves sharing work-at-home tips.

Abbreviations are used in the medical record.
Abbreviations are used in the medical record. | Source

The ABCs of Medical Abbreviations

Are you drowning in a sea of letters. CHF, RLS, LL, BP, ANA, MS are just a few of the thousands of possible medical abbreviations used in medical records. Many of these have made their way into the public eye through television drug ads. Confused? Here is some information to put that all into perspective including online resources and the best medical abbreviation references in print.

The Use of Medical Abbreviations in Patient Records

You've seen medical abbreviations mentioned in TV and magazine ads with increasing regularity. These shortened forms of medical terms are used in patient records to help save time and money. The health care providers find it easier to write or dictate abbreviations, and those responsible for paying the transcription bills are happy to save on transcription costs.

Whether you agree with this or not, medical abbreviations are here to stay. Listed below are resources for your medical abbreviation search whether you work in a medical office or are a layperson interested in better understanding your medical records.

Your Medical Abbreviation Use

Do you use medical abbreviations either at work or in school?

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Common Disease Abbreviations

Here is a list of some abbreviations you may have come across in your own health or in advertising.

  • RLS = Restless leg syndrome.
  • COPD = Chronic obstructive pulmonary disease.
  • MI = Myocardial infarction.
  • OSA = Obstructive sleep apnea.
  • TIA = Transient ischemic attack (stroke).
  • CA = Cancer.

Common Physical Exam Abbreviations

BP = Blood pressure.

HEENT = Head, eyes, ears, nose, throat.

PERRLA = Pupils equal, round, reactive to light and accommodation.

WDWN = Well developed, well nourished.

NAD = No acute distress.

RRR = Regular rate and rhythm.

EOM = Extraocular movements.

JVD = Jugular venous distension.

DTR = Deep tendon reflexes.

NCAT = Normocephalic, atraumatic.

The Best Medical Abbreviations Reference in Print

Medical Abbreviations: 32,000 Conveniences at the Expense of Communication and Safety
Medical Abbreviations: 32,000 Conveniences at the Expense of Communication and Safety

This is a must-have reference for medical personnel including medical transcriptionists. The edition I have is well worn, and I wouldn't want to do my job without it.

 

Lab Test Abbreviations

Here is just a short selection from the many lab tests that your health care provider might run.

  • CMP = Complete metabolic panel.
  • BMP = Basic metabolic panel.
  • PFT = Pulmonary function tests.
  • LFT = Liver function tests.
  • TSH = Thyroid-stimulating hormone.
  • PSA = Prostate-specific antigen.
  • UA = Urinalysis.
Visit Lab Tests Online for comprehensive information about lab tests including their abbreviations as well as how to understand your lab results.

The Eyes Have It

When I was taking transcription classes, the abbreviations for the right and left eye kept tripping me up. Here they are:

  • Right eye is OD which stands for oculus dexter.
  • Left eye is OS which stands for oculus sinister.
  • Both eyes is OU which stands for oculi uterque.
Here is a breakdown for Latin language lovers:

  • Oculus = eye
  • Dexter = right. Some adjectives for this are favorable and skillful.
  • Sinister = left. Unlucky and evil are adjectives for this. You can see this is related to the old attitude about lefties.
  • Uterque = both. The word 'each' is another meaning.

Some drugs are shortened to abbreviations such as HCTZ for hydrochlorothiazide.
Some drugs are shortened to abbreviations such as HCTZ for hydrochlorothiazide. | Source

Dangerous Abbreviations

How can an abbreviation be dangerous? By being misunderstood in handwritten form. Some abbreviations lend themselves to this problem more than others. Some can produce a small error or lead to larger problems with medication dosing.

Here are just a few of the abbreviations considered dangerous which health care providers should consider eliminating from their vocabulary:

  • U for unit which is sometimes mistaken as a number. Use the word unit instead.
  • q.o.d. for every other day which is sometimes mistaken for q.d. (daily) or q.i.d. (4 times daily). Use every other day instead.
  • IU for international units is sometimes mistaken for IV for intravenous. Use units instead.

Not all facilities consider these dangerous. For more information, the Institute for Safe Medicine Practices has put together a useful list of the most common dangerous medical abbreviations available as a pdf file.

Know Your Rights as a Health Care Consumer

One of the most important things to remember is that one abbreviation could stand for several different things. Transcriptionists usually are given guidelines as to how to handle these abbreviations in a report.

We are all health care consumers. If you are unsure of what they mean when reading your lab results or medical records, don't be afraid to ask. You have a right to know.

Abbreviation Overkill in the Media

Do you think ads that use medical abbreviations are just gimmicks to sell drugs.

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Slang vs. Abbreviations

Medical slang and abbreviations are not usually one in the same. Some slang examples are cath for catheter, temp for temperature, and crit for hematocrit. As a medical transcriptionist, I've found this is becoming more common language found in the medical record.

© 2009 PatriciaJoy

Thanks for stopping by. Do you use medical abbreviations in your work?

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    • Ninatheblackhai profile image

      Nina 4 years ago from Flint, MI

      If I ever wanted to get into medical transcription, I would definitely start here. Excellent!

    • WriterJanis2 profile image

      WriterJanis2 5 years ago

      What a great resource!

    • profile image

      anonymous 5 years ago

      Nice info, but using abbreviations sometimes might be confusing as different countries have their own abbreviations.

    • HealthfulMD profile image

      Kirsti A. Dyer 6 years ago from Northern California

      Helpful resource for those trying to figure out all of the medical abbreviations.

    • profile image

      hissavinggrace4u 6 years ago

      I have RLS and GAD. Thank you for the information and good luck.

    • sidther lm profile image

      sidther lm 6 years ago

      Great info! I always get mixed up on the eyes- I know which is which but it always drives me nuts trying to remember what they stand for!

    • SandyMertens profile image

      Sandy Mertens 6 years ago from Frozen Tundra

      Thanks for the useful information on medical abbreviations.