8 Abbreviations in Medical Documents
Formatting Abbreviations
Abbreviations that are written in all capital letters do NOT require periods between the letters.
Many lowercase abbreviations require periods between the letters. If an abbreviation with punctuation occurs at the end of a sentence, the period after the last letter also ends the sentence.
Example:
Administer the medications p.r.n.
NOT Administer the medications p.r.n..
Click here for a list of common medical abbreviations.
General Rules
Reports from a Voice File
NEVER abbreviate a word that is dictated in full except for metric units of measurement.
Examples
The patient has a 3 cm scar on her knee. (voice file said ‘centimeter’)
To irrigate the wound, 4 L of saline was used. (voice file said ‘litre’)
She delivered a 6-pound baby girl. (recall that non-metric units (pounds, inches, ounces) must be spelled out in full, and, when they precede a noun that they are describing, must be hyphenated)
The patient is 5 feet 4 inches. (no comma between feet and inches!)
Transcribe abbreviations as dictated in the voice file, unless the meaning is unclear in which case you must spell them out for clarification.
Abbreviations that are acceptable and even preferred over the expanded form include:
- Pap smear
- INR and other lab terms
- labs
- IV
- MRI
- CT
- OR 3 (instead of operating room 3)
Exceptions
Do NOT use abbreviations in the following sections of a report:
- PREOPERATIVE/POSTOPERATIVE DIAGNOSIS
- ADMITTING OR DISCHARGE DIAGNOSIS
- IMPRESSION
- PROCEDURES
Do NOT abbreviate breaths per minute and respirations per minute to bpm or rpm. The abbreviation bpm (or BPM) means ‘beats per minute’ and is used when reporting a patient’s heart rate.
Time
Use a.m. or AM (ante meridiem) and p.m. or PM (post meridiem). Lower case with periods is preferred.
Error-prone and Forbidden Abbreviations
Do NOT use the dangerous abbreviations and notations identified by the ISMP (Institute for Safe Medication Practices)
NEVER use abbreviations for drug names.
Do NOT expand the short form ‘trach’ unless you know for sure which expanded word the dictator intended: tracheostomy or tracheotomy.
Brief Forms (A Form of Medical Slang)
Brief forms must be expanded out to their full forms in order to avoid confusion.
Examples:
| Brief Form | Full Form |
| alk phos | alkaline phosphatase |
| amp | ampule or ampicillin |
| appy | appendectomy |
| bicarb | bicarbonate |
| bili | bilirubin |
| chem | chemistry (unless it is a brand name like Chem-7™) |
| crit | hematocrit |
| decubitus | decubitus ulcer |
| echo | echocardiogram |
| exlap | exploratory laparotomy |
| gent | gentamicin |
| lytes | electrolytes |
| meds | medications |
| peds (pronounced ‘peeds’) | pediatricians/pediatrics |
| postop | postoperative; postoperatively |
| preop | preoperative, preoperatively |
| sat | saturation |
| temp | temperature |
| vanc | vancomycin |
Exceptions
Heme does NOT necessarily represent Hemoccult™, therefore do NOT expand it out
Example: …heme-positive stools
Both ‘pro time’ and ‘prothrombin time’ are acceptable, but do NOT use protime or proTime
References
Sims, L. M. (2008). The Book of Style for Medical Transcription (3rd ed.). Modesto, California, United States of America: Association for Healthcare Documentation Integrity.
Insertion of a breathing tube through a surgical incision into the trachea. May be long-term or permanent.
Create an artificial opening in the trachea.
Brief forms are not formal abbreviations, rather, they are common short forms used in the medical community.
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