Medical Abbreviations in the Health Record

Are you drowning in a sea of letters. CHF, RLS, LL, BP, ANA, MS are just a few of the thousands of possible medical abbreviations used in medical records. Many of these have made their way into the public eye through television drug ads. Confused? Here is some information to put that all into perspective including online resources and the best medical abbreviation references in print.

You've seen medical abbreviations mentioned in TV and magazine ads with increasing regularity. These shortened forms of medical terms are used in patient records to help save time and money. The health care providers find it easier to write or dictate abbreviations, and those responsible for paying the transcription bills are happy to save on transcription costs.

Whether you agree with this or not, medical abbreviations are here to stay. Listed below are resources for your medical abbreviation search whether you work in a medical office or are a layperson interested in better understanding your medical records.

Here is a list of some abbreviations you may have come across in your own health or in advertising.

• RLS = Restless leg syndrome.
• COPD = Chronic obstructive pulmonary disease.
• MI = Myocardial infarction.
• OSA = Obstructive sleep apnea.
• TIA = Transient ischemic attack (stroke).
• CA = Cancer.

Here is just a short selection from the many lab tests that your health care provider might run.

• CMP = Complete metabolic panel.
• BMP = Basic metabolic panel.
• PFT = Pulmonary function tests.
• LFT = Liver function tests.
• TSH = Thyroid-stimulating hormone.
• PSA = Prostate-specific antigen.
• UA = Urinalysis.

When I was taking transcription classes, the abbreviations for the right and left eye kept tripping me up. Here they are:

• Right eye is OD which stands for oculus dexter.
• Left eye is OS which stands for oculus sinister.
• Both eyes is OU which stands for oculi uterque.

• Oculus = eye
• Dexter = right. Some adjectives for this are favorable and skillful.
• Sinister = left. Unlucky and evil are adjectives for this. You can see this is related to the old attitude about lefties.
• Uterque = both. The word 'each' is another meaning.

How can an abbreviation be dangerous? By being misunderstood in handwritten form. Some abbreviations lend themselves to this problem more than others. Some can produce a small error or lead to larger problems with medication dosing.

Here are just a few of the abbreviations considered dangerous which health care providers should consider eliminating from their vocabulary:

• U for unit which is sometimes mistaken as a number. Use the word unit instead.
• q.o.d. for every other day which is sometimes mistaken for q.d. (daily) or q.i.d. (4 times daily). Use every other day instead.
• IU for international units is sometimes mistaken for IV for intravenous. Use units instead.

Not all facilities consider these dangerous. For more information, the Institute for Safe Medicine Practices has put together a useful list of the most common dangerous medical abbreviations available as a pdf file.