Transcription
Preferred Clinical Abbreviation ListV1.6 (27 February 2013)
Preferred Clinical Abbreviation List27 February 2013 v1.6IntroductionAbbreviations have a long tradition in medicine and used correctly can assist in the rapidcommunication of information about a patient. However, since some abbreviations can havemultiple meanings, or are only used regularly within one speciality, using them can represent ahazard to the patient if the abbreviation is misinterpreted.Whilst writing information in full will always be preferred as the best way to avoid ambiguity, it isaccepted that they are commonly used in medical communications.As a means of promoting the accurate transfer of information between professionals and strikinga practical balance, this document acts as a list of approved abbreviations which can be used ininteragency communications. It will also provide patients with a dictionary of medicalabbreviations helping them to understand medical records and correspondence.The most obvious use of such a directory will be the transfer of information between primary andsecondary care. However, it is also useful for writing patient notes to assist trainees, locums andother specialities, or when primary care notes are transferred between practices as patientsmove.Abbreviations not included in this document should be written in full in correspondence betweenagencies.Dr Jonathan HarnessOn behalf of Gateshead Information Network.
Abbreviation/7/52/40/12 / / BPDBPSBPCABG/S or nslationDaysWeeksWeeks GestationMonthsPresent or Noted / Present Significantly / Present in ExcessEquivalent toAbdominal Aortic AneurysmArterial Blood Gas also "Sats"Angiotensin Converting Enzyme (ACE) InhibitorAnterior Cruciate LigamentAir Entry to LungsAccident and EmergencyAtrial FibrillationAngiotensin Receptor BlockerAtrial Septal DefectAbdominal X-RayTwice a DayBasal Cell CarcinomaBendroflumethiazideBody Mass IndexBowels Not OpenedBowels OpenBlood PressureDiastolic Blood PressureSystolic Blood PressureCoronary Artery (Bypass) Graft/SurgeryCalcium Channel BlockerChronic Fatigue SyndromeCoronary Heart DiseaseCentral Nervous SystemComplains ofChronic Obstructive Airways Disease (COPD preferred)Combined Oral ContraceptiveChronic Obstructive Pulmonary DiseaseCreatinineCatheter specimen of urineComputerised Axial TomographyCardiotocographCerebrovascular Accident
CVDCVSCX or CxCXRD&VD/HDIP, PIPDLEDMDNADNARDVTDXTECGEEGENTEPAUESRFBCFBGF/H or FHFHH/RFRHFROMFTNDGCSGI or GITGORDGUT or GUSGUMHbHIHNPUHRHSHtHxIBDIBSIGTCardiovascular DiseaseCardiovascular SystemCervixChest X-rayDiarrhoea and VomitingDrug HistoryDorsal/proximal interphalangeal jointsDiscoid Lupus ErythematosusDiabetes MellitusDid Not AttendDo Not Attempt ResuscitationDeep Vein ThrombosisDeep X-ray , Nose & ThroatEarly Pregnancy Assessment UnitErythrocyte Sedimentation RateFull Blood CountFasting Blood GlucoseFamily HistoryFoetal Heart Heard/RegularFreeman Road HospitalFull Range of MovementFull Term Normal DeliveryGlasgow Coma ScaleGastro Intestinal/TractGastro-Oesophageal Reflux DiseaseGenito Urinary Tract/ SystemGenito-Urinary MedicineHaemoglobinHead InjuryHas Not Passed UrineHeart RateHeart SoundsHeightHistory (of complaint)Irritable Bowel DiseaseInflammatory Bowel SyndromeImpaired Glucose Tolerance
IGTNIMBIOPIUCDIUDIUSIVPIxJVPK KUBLFTLIFLIHLOCLNLPL/R/ MTXNa NADNBINocteNSTEMIN&VIn Growing ToenailIntermenstrual BleedingIntra-ocular PressureIntra-uterine contraceptive deviceIntra-uterine deathIntra-uterine systemIntravenous PyelogramInvestigationsJugular Venous PressurePotassiumKidneys, Ureters, Bladder (xray)Liver Function TestLeft Iliac FossaLeft Inguinal HerniaLoss of ConsciousnessLymph NodeLumbar punctureLeft or Right Inguinal HerniaLower (Uterine) Segment Caesarean sectionLeft Upper QuadrantLeft Ventricular Diastolic DysfunctionLeft Ventricular Systolic DysfunctionIn the MorningMedical Admissions UnitMean Corpuscular VolumeMyalgic Encephalomyelitis (Chronic Fatigue Syndrome preferred)MetastasesMyocardial infarction (NSTEMI or STEMI preferred)Magnetic Resonance ImagingMultiple Sclerosis (Write in full: Mitral Stenosis)Musculo-Skeletal SystemMental State ExaminationMid-Stream Urine Sample (for culture and sensitivity)MethotrexateSodiumNothing Abnormal DiscoveredNo Bone InjuryAt NightNon ST Elevation Myocardial InfarctionNausea & Vomiting
OAo.d.O/EOGDOGTTonomOMORIFotcPPADPCBPEPERLAPF / PEFRPltPMPMBPMH also PHxPNDPOPOPPRPRNPTCAPTSDPUPVPVDqds (or) qidQEHResp / RRRARDSRIFRIHR/LIFRSRSIOsteoarthritisOnce a DayOn ExaminationOesophago-gastro-duodenoscopyOral Glucose Tolerance TestAt Night (when written next to medication dosing only)In the Morning (when written next to medication dosing only)Otitis MediaOpen Reduction and Internal Fixation (of fracture)Over the counter (bought medication)PulsePeripheral Arterial DiseasePost Coital BleedingPulmonary EmbolismPupils equal and reacting to light and accommodationPeak Flow / peak expiratory flow ratePlateletsPost mortem examinationPost menstrual BleedingPrevious Medical HistoryParoxysmal Nocturnal DyspnoeaPer Orim (by mouth)Progesterone Only PillPer RectumAs RequiredPercutaneous transluminal coronary angioplastyPost Traumatic Stress DisorderPeptic Ulcer OR Passed urinePer VaginaPeripheral Vascular DiseaseFour times a dayQueen Elizabeth HospitalRespiration (Rate)Rheumatoid ArthritisRespiratory Distress SyndromeRight Iliac FossaRight Inguinal HerniaRight/Left IliacfossaRespiratory SystemRepetitive Strain Injury
Road Traffic Accident (write renal tubular acidosis in full) Note that whilstRoad traffic accident is in common use, RTC is the preferred term.RTCRoad Traffic CrashRUQRight Upper QuadrantRVIRoyal Victoria InfirmaryRxPrescription or TreatmentSBGSerum Blood GlucoseSLRStraight Leg RaisingSMRSubmucosal ResectionSOBShort of BreathSRSinus rhythmSRHSunderland Royal HospitalStatImmediatelySTDSexually Transmitted DiseaseSTEMIST Elevation Myocardial InfarctionSTISexually Transmitted InfectionSVDSpontaneous Vertex DeliverySxSymptomsSkXRSkull X-rayTTemperatureTATTTired all the TimeTBTuberculosisTCITo come in-date or fact that a person is due to be admitted to hospitaltds (or) tidThree Times a DayTFTsThyroid Function TestTHRTotal Hip ReplacementTIATransient Ischaemic AttackTKRTotal Knee ReplacementTMTympanic MembraneTOP (MTOP/STOP) Termination of pregnancy (Medical / Surgical )TShRTotal Shoulder ReplacementTURP/TTransurethral resection of Prostate / (Bladder) TumourUCUlcerative ColitisU&EsUrea and ElectrolytesUSSUltra Sound ScanUTIUrinary Tract InfectionVFVentricular Fibrillation(RTA)VTVTEVentricular TachycardiaVenous Thromboembolism
wbcWdWtWhite Blood Cell CountWardWeightNON-PREFERRED ABBREVIATION LISTFracture. May be written on hand written discharge letters. However,#should not be used within EMIS. (Depending on EMIS settings maydisplay either as # or as )Ambiguous: could refer to Aortic Regurgitation or Aortic valveARreplacement. Write in fullAmbiguous: could refer to Abdominal System or Aortic Stenosis. Write inASfullBSAmbiguous: could refer to Bowel sounds or breath sounds. Write in full.CaAmbiguous: could refer to Carcinoma or calcium. Write in fullCongestive cardiac (heart) failure. Use of more precise LVSD / LVDD isCCF / CHF / HFpreferred. If diagnosis uncertain, CCF may be used.Ambiguous: could refer to Erectile Dysfunction or Emergency Department.EDWrite in fullGUAmbiguous: could refer to Genito-urinary or Gastric ulcer. Write in fullAmbiguous: could refer to Mitral incompetence or Myocardial infarction.However, MI in regular use by all specialities, so may be used forMIMyocardial Infarction. Ideally write in full or use STEMI or NSTEMI, andwrite Mitral IncompetenceAmbiguous: could refer to Multiple Sclerosis or Mitral Stenosis. However,MSMS is widely used by public for Multiple Sclerosis. Therefore, accepted foruse as multiple sclerosis. Mitral stenosis should be written in full.Ambiguous. Could refer to Pelvic Inflammatory Disease ORPIDProlapsed Intervertebral Disc. Write in fullAmbiguous could refer to Renal (Kidney) Function tests ORRFTRespiratory Function tests. Write in fullR/LRight and left should be written in fullAmbiguous: could refer to soft tissue injury OR sexually transmittedSTIillness. Use NBI for non-bony injury and STD for sexually transmitteddisease.VEAmbiguous: could refer to vaginal examination or ventricular ectopic.Should be written in full.UNITS OF MEASUREkm / m / cm / mmkg / g / mg / microg /pgL / mL / microL / pLmmHgkilometre / metre / centimetre / millimetreKilogramme / gramme / milligramme / microgramme /picogrammenote: μg or mcg are not approvedLitre / millilitre / microlitre / picolitreNote: μL is not approvedfor measurement of blood pressure
unitsinternational units. Do not write iu.Except to record what patients have reported, imperial measurements should notbe used:ft / in / st / lb / ozFeet / inches / stones / pounds / ouncesnote: ‘miles' should be written in fullAcknowledgements: the abbreviations list is based in part on the RCGP abbreviation list.However, variations have been made to reflect local use (both to remove and add abbreviations.)Preferred Abbreviation ListDate of Publication:27 February 2013Version:1.6 (Draft)Author:Dr Jonathan HarnessReview Due:27 February 2015Version ControlAmendments [v1.2] (following consultation with GPs and QEH): AS removed felt to be too ambiguous MCL removed felt not to be in common use mmHG changed to mmHg Ca removed felt to be too ambiguous Cr added Na added K added Plt added VTE added AoR removed: felt to be too ambiguous AMI changed to MIAmendments [v1.4]: IOP Intraocular pressure addedAmendments [v1.5] Front page added, amendment to introductionAmendments [v1.6] RTC added and note added to RTA that RTC is preferred term ED added to non-preferred list since ambiguous SRI amended to SRH CTG added TOP amended with MTOP and STOP qualifiers IBD added 2013, Gateshead Clinical Commissioning Group. This document may be freely distributed andcopied within the NHS. It may not be used for non-NHS or commercial purposes without priorwritten consent.
Cover photo: 2012 J Harness
MCL removed felt not to be in common use mmHG changed to mmHg Ca removed felt to be too ambiguous Cr added Na added K added Plt added VTE added AoR removed: felt to be too ambiguous AMI changed to MI Amendments [v1.4]:
