Abbreviations Commonly Found in Medical Notes

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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

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