Abbreviations in Medical Records
Knowing the meaning of the abbreviations in medical records is important if you work in the medical field. These abbreviations are used for a number of purposes and knowing what they mean can help you tremendously as a medical professional.
Even as a patient, knowledge of medical record abbreviations is helpful. The various codes and abbreviations all have significance on a medical record. They are used not only to identify what type of health conditions or procedures a person has, but also to assist with the billing process.
Medical Abbreviations
The following is a list of some common medical abbreviations that are found in medical records.
- Ad lib-At liberty (patient can move about as desired)
- BID-Twice daily
- BP-Blood Pressure
- C/O-Complaint of (patient expressing concern about medical conditions)
- CVA-Cerebrovascular Accident (stroke)
- D/C-Discharge
- DDX-Differential Diagnosis
- DNR-Do Not Resuscitate
- FX-Fracture
- H&P-History and Physical Examination
- H/O-History of
- In vitro-In the laboratory
- In vivo-In the body
- IU-International Units
- LBP-Lower Back Pain
- Mg-Milligrams
- Ml-Milliliters
- N/V-Nausea/vomiting
- NPO-Nothing by mouth
- P-Pulse
- P.R.N.-As needed
- Q. D.-Each day.
- Q.I.D.-Four times daily.
- Q2h: Every 2 hours.
- Q3h: Every 3 hours.
- QAM: Each morning.
- QHS: At each bedtime
- QOD: Every other day
- QPM: Each evening
- R/O-Rule Out
- SOB-Shortness of Breathe
- T-Temperature
- Tab-Tablet
- URI-Upper Respiratory Infection
- Ut dict-As directed
- UTI-Urinary Tract Infection
- VSS-Vital Signs Stable
- Wt-Weight
Approved Charting Medical Abbreviations
The medical record is a very detailed report of your medical history. Everything from baby immunizations to major surgeries and the types of medications that you are taking can be found within your medical records. As such, the abbreviations that are used on medical records are very important for administering treatment.
These abbreviations are so vital that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that medical facilities create a list of unacceptable medical abbreviations in order to prevent problems of misdiagnosis or other potential errors.
Unfortunately, medical errors are made when the wrong abbreviations are used or when illegible writing makes the proper abbreviation hard to decipher. The abbreviations in a medical record provide all medical professionals with a very concise method of determining a variety of information. The abbreviations alone can provide information on the patient’s status and they are used as a means of sharing information between medical professionals that are providing treatment.
Medical Record Abbreviations for Payment
The abbreviations in medical records play a very important role in compensation for medical services as well. If you are interested in a career as a medical coder, biller or health information technologist, it is vital that you understand and have a working knowledge of the common abbreviations that are found in medical records.
When you work with medical records on a consistent basis there are certain codes you will become familiar with. This is particularly true if you work in a specific type of health care environment or health specialty. There are resources such as the Current Procedural Terminology (CPT) books and the International Classification of Diseases (ICD) listings that are very important within the medical community.
It is required that medical professionals have a very thorough understanding of these codes as they are used by professionals to determine how much a patient is charged for medical procedures and services. Hospitals and medical facilities rely on their billing departments to accurately code bills to ensure that patients and insurance companies are properly charged for medical services.