The most common shorthands Physician use in a Medical Record

Overview

You, me, and every one of us is prone to the use of shorthands in our daily life. Since the beginning of the digital era, we are all having a fast-paced life, and time has become one of the biggest constraints. This has introduced us to the usage of shorthands in our life. We use numerous shorthands with our friends over chat. We never spell a word on the whole while texting,  just to save time and also our laziness to type.

In the case of physicians, they have heaving responsibilities making them vulnerable to a hectic schedule. Scribing a medical record consumes humongous time as it may even last more than a thousand pages in most cases. As we know, a medical record is a complete record of the medical history of a patient with all the details from medications, diagnoses, and tests inscribed in it.  This compels physicians to use numerous shorthands in order to save time. The usage of abbreviations and acronyms in a medical record is a fragile move, as it may go wrong in some cases.

In this blog, we will have a detailed look at – what shorthand do doctors use the most, the downside of their usage in medical records, and the solution provided by the firms that provide medical records review services.

LezDo TechMed provides top quality medical record reviews with all the shorthands deciphered for you.

What are shorthands in medical records?

The shorthands in a medical record are the abbreviations, acronyms, or any medical codes used to represent a medical term or practice. This has been a prominent tactic followed by physicians in order to save time. Although this has been in practice for a very long time, most of common people or personal injury lawyers are not familiar with it. The shorthand, in some cases, even has more than one meaning, leading the common people and lawyers to be confused. However, in any case, the usage of shorthands in medical records is not going to be pulled away from the practice. It is better we equip ourselves with some of the common shorthands used in medical records.

The downside of the usage of shorthands

The usage of shorthands in medical records has not turned out to be a very good practice. It has gone wrong in many occasions. Although there have been many unified codes and laws, abbreviations have been misunderstood and resulted in wrong actions. In some cases, the lab technicians have misunderstood the shorthand used by the physician and preceded with irrelevant tests on the patient. In some cases, it has also lead to serious affliction to the patients.

When we consider personal injury claims, the role of medical records in receiving a reasonable claim amount is crucial. A lawyer is a person who is a professional in law and legal terms, whereas medical terms are not his cup of tea. But in the case of a personal injury claim, the data in the medical record is to be understood thoroughly by reviewing it and summarising it into a medical record review report. This is a two or three pages report that includes only the crucial points that will help the client receive a deserving compensation

The problem is that the lawyers may not be aware of all the medical shorthands. In some cases, the meaning of the shorthands may differ in different medical organizations. This may lead to a misunderstanding. The lawyer may mistake a shorthand that is a severe medical problem for a non-serious one and may not include it in his key points to the session with the jury. This will definitely decrease the claim amount the client may be worthy to receive.

Medical record review services – A solution?

A medical record review service provider is a team of professionals in the medical arena who review the medical records, understand the medical data of the patient and prepares a medical record review report. The report summarizes the key details of the medical record for a better understanding of  the lawyers and the jury. As medical record reviewers are experts in the medical arena, they would be aware of all the shorthands used by a physician. Even in cases where the shorthand may have two different meanings, they would figure out what the physician means in the particular case. So, it is always a better option to consult a medical record review outsourcing company for summarizing a medical record. Outsourcing the medical chart reviewing would help the attorneys save time and get a precise medical record review report.

Common shorthands in a medical record

The list below has some of the common medical shorthands and their meanings.

• A & P – Anatomy and physiology
• Ab – Abortion
• Abd – Abdominal
• ABG – Arterial Blood Gas
• a.c. – Before meals
• ac & cl – acetest and clinitest
• ACLS – advanced cardiac life support
• AD – right ear
• ADL – activities of daily living
• ad lib – as desired
• adm – admission
• afeb – afebrile, no fever
• AFB – acid-fast bacillus
• AKA – above the knee
• Alb – albumin
• alt dieb – alternate days (every other day)
• am – morning
• AMA – against medical advice
• ARDS – acute respiratory distress syndrome
• AS – left ear
• ASA – aspirin asap
• (ASAP) – as soon as possible
• AU – both ears
• BE – barium enema
• Bid – twice a day
• bil, bilateral – both sides
• BK – below knee
• BKA – below the knee amputation
• Bl – blood
• bl wk – blood work
• BLS – basic life support
• BM – bowel movement
• BOW – bag of waters
• B/P – blood pressure
• Bpm – beats per minute
• BR – bed rest
• c-spine – cervical spine
• CA – cancer
• CAD – coronary artery disease
• Cal – calorie
• CAT – computerized axial tomography
• Cath – catheter
• CBC – complete blood count
• CCU – coronary care unit, critical care unit
• CHD – coronary heart disease
• CHF – congestive heart failure
• CHO – carbohydrate
• Chol – cholesterol
• D & C – dilation and curettage
• DAT – diet as tolerated
• DNA – deoxyribonucleic acid
• DNR – do not resuscitate
• DOA – dead on arrival
• DOB – date of birth
• DPT – diphtheria, pertussis, tetanus
• DRG – diagnosis-related grouping
• D/S – dextrose in saline
• DT’s – delirium tremens
• EBL – estimated blood loss
• ECG – electrocardiogram
• ED – emergency department
• EEG – electroencephalogram
• EENT—eyes, ears, nose, throat
• EKG – electrocardiogram
• EMG – electromyogram
• EOA – esophageal obturator airway
• ESR – erythrocyte sedimentation rate
• FBOA – foreign body obstructed airway
• FBS – fasting blood sugar
• FBW – fasting blood work
• FF (F. Fl) – force fluids
• FH – family history
• FHS – fetal heart sounds
• GB – gallbladder
• GI – gastrointestinal
• GU – genitourinary
• GTT – glucose tolerance test (pancreas test)
• gtt(s) – drop(s)
• gyn – gynecology
• H & H – hemoglobin and hematocrit
• HCG – human chorionic gonadotrophin
• Hct – hematocrit
• HDL – high-density lipoprotein
• ICP – intracranial pressure
• ICU – intensive care unit
• IM – intramuscular
• Ing – inguinal
• Inj – injection
• IPPB – intermittent positive pressure breathing
• IVF – in vitro fertilization
• IVP – intravenous pyelogram
• K+ – potassium
• KCl – potassuim chloride
• KUB – kidney, ureter, bladder
• L – lumbar
• L & D – labor and delivery
• LDL – low-density lipoprotein
• Liq – liquid
• LLQ, LLL – left lower quadrant (abdomen),
• lobe (lung)
• LMP – last menstrual period
• LOC – level of consciousness
• LP – lumbar puncture
• MAST – medical antishock trousers
• MCI – mass casualty incident
• MI – myocardial infarction
• Os – mouth
• OS – left eye
• OU – both eyes
• PET – positron emission tomography
• PH – past history
• pH – hydrogen ion concentration
• PID – pelvic inflammatory disease
• q – every
• qd – every day
• qh – every hour
• q2h, q3h, …—every two hours, every three hours, …
• qhs – every night at bedtime
• qid – four times a day
• qns – quantity not sufficient
• qod – every other day
• qs – quantity sufficient
• RAIU – radioactive iodine uptake study
• RBC – red blood cell/count
• reg – regular
• Rh – rhesus
• RK – radial keratomy
• RL – ringer’s lactate
• RLQ, RLL – right lower quadrant (abdomen), lobe (lung)
• RML – right middle lobe (lung)
• SGOT – serum glutamic oxaloacetic transaminase
• SGPT – serum glutamic pyruvic transaminase
• SIDS – sudden infant death syndrome
• Sig: – label/write
• SL – sublingual
• SMAC – sequential multiple analysis computer
• SOB – shortness of breath
• SVD – spontaneous vaginal delivery
• SVN – small volume nebulizer
• TIA – transient ischemic attack
• TUR – transurethral resection
• TV – tidal volume
• TVH – total vaginal hysterectomy
• URI – upper respiratory infection
• US – ultrasonic
• UTI – urinary tract infection
• V/S – vital signs
• WA – while awake
• WBC – white blood cell/count
• w/c – wheelchair

See the sample medical record with all shorthands.

Final thoughts

Hope you are now aware of some of the common shorthands used by physicians in a medical record. It is very crucial to review a medical record without mistaking any of the shorthands for a different meaning. The medical shorthands are critical at times for your understanding, but with the help of expert medical record review companies like LezDo techmed you can avail a medical record review service and benefit a full reap of your personal injury claim amount.

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