Abbreviations Commonly Found in Medical Notes

When a patient is first admitted to hospital, a standard series of questions, investigations, and results relating to their physical examination is recorded in the medical notes.

This is known as ‘medical clerking’ and is essentially the story (history) of the patient’s illness to date. After interpretation of the initial clerking is mastered, it is usually easy to understand subsequent entries in the notes because these are mostly brief updates.

Pharmacists should write in the medical notes to communicate information relating to the pharmaceutical care of the patient to the medical staff if immediate action is not required. The information should significantly influence
the care of the patient, or ensure that information is available to all members of the medical and nursing teams.

The notes are a legal document, and if the pharmacist has contributed to, or attempted to contribute to, the patient’s care, this should be documented.

Below is the list of some common abbreviations found in Medical notes:

S.No.	Short Name	Full Name
1	ABG	Arterial blood gases
2	ACTH	Adrenocorticotrophic hormone
3	ADH	Antidiuretic hormone
4	AF	Atrial fibrillation
5	AFB	Acid-fast bacilli
6	Ag	Antigen
7	AIDS	Acquired immunodeficiency syndrome
8	ALL	Acute lymphoblastic leukaemia
9	AML	Acute myeloid leukaemia
10	ANF	Antinuclear factor
11	APTT	Activated partial thromboplastin time
12	ARDS	Acute respiratory distress syndrome
13	ASD	Atrial septal defect
14	AST	Aspartate transaminase
15	A&W	Alive and well
16	AXR	Abdominal X-ray
17	Ba	Barium
18	BBB	Bundle branch block
19	BMT	Bone marrow transplant
20	BP	Blood pressure
21	BS	Breath sounds or bowel sounds
22	C/O	Complaining of
23	Ca	Carcinoma or cancer
24	CABG	Coronary artery bypass graft
25	CAPD	Continuous ambulatory peritoneal dialysis
26	CCF	Congestive cardiac failure
27	CHD	Congenital heart disease
28	CHF	Chronic heart failure
29	CLL	Chronic lymphoblastic leukaemia
30	CML	Chronic myeloid leukaemia
31	CMV	Cytomegalovirus
32	CNS	Central nervous system
33	COPD	Chronic obstructive pulmonary disease
34	CPAP	Continuous positive airways pressure
35	CREPS	Crepitations
36	CSF	Cerebrospinal fluid
37	CSU	Catheter specimen of urine
38	CT	Computed tomography
39	CVA	Cerebrovascular accident
40	CVP	Central venous pressure
41	CVS	Cardiovascular system
42	CXR	Chest X-ray
43	D&C	Dilatation and curettage
44	D&V	Diarrhoea and vomiting
45	DDx, ΔΔ	Differential diagnoses
46	DHx	Drug history
47	DIC	Disseminated intravascular coagulation
48	DM	Diabetes mellitus
49	DNA	Did not attend or Deoxyribose nucleic acid
50	DVT	Deep vein thrombosis
51	D/W	Discussed or discussion with
52	Dx, Δ	Diagnosis
53	DXT	Deep X-ray therapy, i.e. radiotherapy
54	EBV	Epstein–Barr virus
55	ECF	Extracellular fluid
56	ECG	Electrocardiogram
57	EEG	Electroencephalogram
58	ELISA	Enzyme-linked immunosorbent assay
59	EMU	Early morning urine
60	ENT	Ear, nose, and throat
61	ERCP	Endoscopic retrograde cholangiopancreatography
62	ESR	Erythrocyte sedimentation rate
63	EUA	Examination under anaesthesia
64	FBC	Full blood count
65	FEV1	Forced expiratory volume in 1 second
66	FFP	Fresh frozen plasma
67	FHx	Family history
68	FSH	Follicle-stimulating hormone
69	FSHx	Family and social history
70	FVC	Forced vital capacity
71	G6PD	Glucose-6-phosphate dehydrogenase
72	GA	General anaesthesia
73	GABA	γ-aminobutyric acid
74	GFR	Glomerular filtration rate
75	GGT	γ-glutamyl transpeptidase
76	GH	Growth hormone
77	GI	Gastrointestinal
78	GU	Gastric ulcer or genitourinary
79	GVHD	Graft-versus-host disease
80	Hb	Haemoglobin
81	HBV	Hepatitis B virus
82	HCV	Hepatitis C virus
83	HIV	Human immunodeficiency virus
84	HLA	Human leucocyte antigen
85	HPC	History of presenting complaint
86	HRT	Hormone replacement therapy
87	HSV	Herpes simplex virus
88	IBD	Inflammatory bowel disease
89	ICP	Intracranial pressure
90	IDDM	Insulin-dependent (type 1) diabetes mellitus
91	Ig	Immunoglobulin
92	IHD	Ischaemic heart disease
93	IM	Intramuscular
94	INR	International normalized ratio
95	ISQ	Idem status quo (i.e. unchanged)
96	IT	Intrathecal
97	ITP	Idiopathic thrombocytopenic purpura
98	IUD	Intrauterine device
99	IV	Intravenous
100	IVC	Inferior vena cava
101	Ix	Investigations
102	JVP	Jugular venous pressure
103	KCCT	Kaolin cephalin clotting time
104	LBBB	Left bundle branch block
105	LFT	Liver function tests
106	LH	Luteinizing hormone
107	L°K°K°S°	Liver, kidneys, spleen (° = normal)
108	LP	Lumbar puncture
109	LVF	Left ventricular failure
110	MC&S	Microscopy, culture, and sensitivities
111	MCHC	Mean corpuscular haemoglobin concentration
112	MCV	Mean corpuscular volume
113	MI	Myocardial infarction
114	MND	Motor neurone disease
115	MSU	Midstream urine
116	N&V	Nausea and vomiting
117	NAD	Nothing abnormal detected
118	NG	Nasogastric
119	NIDDM	Non-insulin-dependent (type 2) diabetes mellitus
120	NKDA	No known drug allergies
121	NSTEMI	Non-ST-elevation myocardial infarction
122	O/E	On examination
123	OA	Osteoarthritis or on admission
124	OC&P	Ova, cysts, and parasites
125	OGTT	Oral glucose tolerance test
126	PC	Presenting complaint
127	PCP	Pneumocystis jirovecii (previously carinii) pneumonia
128	PCV	Packed cell volume
129	PDA	Patent ductus arteriosus
130	PE	Pulmonary embolism
131	PEEP	Positive end-expiratory pressure
132	PEFR	Peak expiratory flow rate
133	PERLA	Pupils equal reactive to light and accommodation
134	PID	Pelvic inflammatory disease
135	PM	Post-mortem
136	PMH	Past medical history
137	PR	Per rectum (through the rectum) or pulse rate
138	PT	Prothrombin time
139	PTH	Parathyroid hormone
140	PTT	Partial thromboplastin time
141	PUO	Pyrexia of unknown origin
142	PV	Per vaginum (through the vagina)
143	RA	Rheumatoid arthritis
144	RAST	Radio-allergosorbent test
145	RBBB	Right bundle branch block
146	RBC	Red blood cell
147	RF	Renal function
148	RIP	Rest in peace (i.e. dead or died)
149	Rh	Rhesus
150	ROS	Rest of systems
151	RS/RES	Respiratory system
152	RTA	Road traffic accident
153	RTI	Respiratory tract infection
154	RVF	Right ventricular failure
155	S₁ S₂	Heart sounds (first and second)
156	SCD/SCA	Sickle cell disease/anaemia
157	SIADH	Syndrome of inappropriate diuretic hormone
158	SLE	Systemic lupus erythematosus
159	SOA	Swelling of ankles
160	SOB	Shortness of breath
161	SOBOE	Short of breath on exercise/exertion
162	ST	Sinus tachycardia
163	STEMI	ST elevation myocardial infarction
164	SVC	Superior vena cava
165	SVT	Supraventricular tachycardia
166	TB	Tuberculosis
167	TBG	Thyroxine-binding globulin
168	TFT	Thyroid function tests
169	THR	Total hip replacement
170	TIA	Transient ischaemic attack
171	TIBC	Total iron-binding capacity
172	TLC	Tender loving care
173	TOE	Transoesophageal echocardiogram
174	TOP	Termination of pregnancy
175	TPN	Total parenteral nutrition
176	TRH	Thyrotropin-releasing hormone
177	TSH	Thyroid-stimulating hormone
178	TURP	Transurethral resection of the prostate
179	U&Es	Urea and electrolytes
180	UC	Ulcerative colitis
181	URTI	Upper respiratory tract infection
182	UTI	Urinary tract infection
183	VDRL	Venereal Diseases Research Lab
184	VF	Ventricular fibrillation
185	VRIII	Variable rate intravenous insulin infusion
186	VSD	Ventricular septal defect
187	VT	Ventricular tachycardia
188	W/R	Ward round
189	WBC	White blood count
190	WCC	White cell count