Overview

You, me, and every one of us have prone to use shorthands in our daily life. After the beginning of the digital era, we are all having a fast-paced life and time has become one of the biggest constraints we face today. 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 our friends just to save some time and also our laziness to type it completely.

In the case of Physicians, although laziness is not the reason, they have heaving responsibilities making them vulnerable to a hectic schedule. As we know, a medical record is a complete record of the medical history of a patient with all the details from medications, diagnoses, tests inscribed in it. Scribing a medical record consumes humongous time as it may even last more than a thousand pages in most cases. This compels the physicians to use numerous shorthands in order to save some time. The usage of abbreviations and acronyms in a medical record is a fragile move as it may go wrong in some cases.

We will have a detailed look at the most commonly used shorthands, the downside of the usage of shorthands in medical records, and the solution provided by the firms that provide medical records review services.

What are shorthands in medical records?

The shorthands in a medical record are the abbreviations, acronyms, or any medical codes used to represent any medical term or practice. This has been a prominent practice followed by physicians in order to save time. Although this has been in practice for a very long time most of the common people or the personal injury lawyers are not familiar with these shorthands. These shorthands in some cases even have more than one meaning leading the common people and lawyers confused. But, 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 in medical records

The usage of shorthands in medical records has not turned out to be a very good practice. The usage of shorthands has gone wrong on many occasions in medical history. Although there have been many unified codes and laws there have been many occasions where the 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. But 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 law 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 the claim amount he deserves.

Check our blog on “How Medical Records and Medical Chart Review helps Attorneys in Personal Injury Cases?” to know more about the role of medicals in a personal injury claim.

The problem we usually face is the lawyers may not be aware of all the medical shorthands. In some cases, the meaning of the shorthands may differ from 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. This is a serious problem to be taken care of.

Medical record review services – A solution?

A medical record review service provider firm is a team of professionals in the medical arena who review the medical records understand the health issues of the patient and prepares a medical record review report that summarizes the key details of the medical record for a better understanding of lawyers and juries. As they are professionals in the medical arena they are aware of all the shorthands used by a physician. Even in cases where the shorthand may have two different meanings, they figure out what the physician means in the particular case as they study the medical record thoroughly. So, it is always a better option to consult a medical record review service firm in the case of summarizing a medical record.

You can have a look at our blog on “Outsourcing the Medical Record Review Services a new normal in 2021?” to have a better understanding of medical review service firms and their role in a personal injury claim.

Most common shorthands used by a Physician in a Medical Record

The list below has some of the medical shorthands and their meanings. Have a look at it and make yourself more aware of the medical shorthands.

  • 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

Final thoughts

Hope you are now aware of some of the common shorthands used by physicians in a medical record. Also, how important it is 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 professionals like LezDo techmed you can avail a medical record review service and benefit a full reap of your personal injury claim amount.