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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.
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.
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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 |
Δ | Used to indicate the current diagnosis |
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