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Common Abbreviations in Medical Notes

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2025-05-20 10:26

Introduction

Abbreviations and acronyms are commonly used in medical notes. If you are unfamiliar with common abbreviations, it can make understanding medical notes challenging. We’ve curated a list of medical abbreviations/acronyms to help you understand entries in the medical notes.

Remember, using ambiguous abbreviations increases the risk of miscommunication. Your hospital may have an approved list of abbreviations.

History

Structure of the medical history Abbreviation Meaning PC Presenting complaint HPC History of presenting complaint PMH/PMHx Past medical history SR Systems review DH/DHx Drug history FH/FHx Family history SH/SHx Social history LMP Last menstrual period h/o History of c With
Usually has a line over the c Ø No/none
Usually written before a symptom (e.g. ØChest pain = No chest pain) ADLs Activities of daily living Timing Number of days = number of days/7 (e.g. 3/7 = 3 days) Number of weeks = number of weeks/52 (e.g. 4/52 = 4 weeks) Number of hours = Xº (e.g. 8º = 8 hours) Medical conditions and procedures

While care should always be taken when using acronyms in notes, it is particularly important for medical conditions, as the same acronym can mean different conditions depending on the specialty.

Abbreviation Meaning AAA Abdominal aortic aneurysm ACS Acute coronary syndrome AF Atrial fibrillation AKI Acute kidney injury ASD Atrial septal defect BCC Basal cell carcinoma BPH Benign prostatic hyperplasia CABG Coronary artery bypass graft CAD Coronary artery disease COPD Chronic obstructive pulmonary disease CF Cystic fibrosis CKD Chronic kidney disease DVT Deep vein thrombosis ESRD/ESRF End-stage renal disease/End-stage renal failure GORD Gastro-oesophageal reflux disease HOCM Hypertrophic obstructive cardiomyopathy IBD Inflammatory bowel disease IBS Irritable bowel syndrome MI Myocardial infarction MM Multiple myeloma MS Multiple sclerosis NSTEMI Non ST-segment elevation myocardial infarction OA Osteoarthritis OGD Oesophagogastro duodenoscopy ORIF Open reduction internal fixation PAD Peripheral arterial disease PE Pulmonary embolism PID Pelvic inflammatory disease PCOS Polycystic ovarian syndrome RA Rheumatoid arthritis SCC Squamous cell carcinoma SLE Systemic lupus erythematosus STEMI ST-segment elevation myocardial infarction STI Sexually transmitted infection UC Ulcerative colitis UTI Urinary tract infection VSD Ventricular septal defect

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Medications

Abbreviation Meaning OD Once daily BD Twice daily TDS Three times daily QDS Four times daily PRN As required SC Subcutaneous IM Intramuscular IV Intravenous Stat Immediately OTC Over the counter OM “omni mane” – Every morning ON “omni nocte” – Every night Neb Nebulised

Examination

Abbreviation Meaning O/E On examination BP Blood pressure RR Respiratory rate Sats Oxygen saturation RA Room air I + II + 0 Heart sounds 1 and 2 heard, with no added sounds BS Bowel sounds RUL/LUL Right/left upper limb RLL/LLL Right/left lower limb RUQ/LUQ Right/left upper quadrant RLQ/LLQ Right/left lower quadrant RIF/LIF Right iliac fossa/left iliac fossa CN Cranial nerve PEARL Pupils equal and reactive to light FROM Full range of movement NAD Nothing abnormal detected/discovered
Commonly used when documenting examination findings (e.g. “Abdominal exam NAD”) SNT Soft, non-tender
Used in the context of documenting abdominal examination findings (e.g. “Abdo SNT”) SLR Straight leg raise +ve / -ve Positive / negative
Commonly used to document examination findings (e.g. “FAST +ve”) + Present ++ Present significantly +++ Present in excess

Investigations

Abbreviation Meaning ABG Arterial blood gas ANA Antinuclear antibody ANCA Anti-neutrophil cytoplasmic antibody BM Capillary blood glucose (short for ‘Boehringer Mannheim’ – a manufacturer of blood glucose test strips) CBG Capillary blood glucose (for blood sugar) or capillary blood gas CTA CT angiography CTG Cardiotocograph CT TAP/CT CAP CT scan of the thorax/chest, abdomen and pelvis CSF Cerebrospinal fluid CSU Catheter specimen of urine CXR Chest X-ray eGFR Estimated glomerular filtration rate ECG Electrocardiogram EEG Electroencephalogram ESR Erythrocyte sedimentation rate FBC Full blood count G+S/G&S Group and save LFTs Liver function tests L&S BP Lying & standing blood pressure INR International normalised ratio MRI Magnetic resonance imaging MRCP Magnetic resonance cholangiopancreatography MSU Mid-stream urine sample OGTT Oral glucose tolerance test PEFR Peak expiratory flow rate TFTs Thyroid function tests U&E Urea and electrolytes US/USS Ultrasound/ultrasound scan VBG Venous blood gas AXR Abdominal X-ray X-match Crossmatch

Other abbreviations

Abbreviation Meaning 1 ATD Adult therapeutic dose
>Used to refer to 1 unit/bag of platelets AMHP Approved mental health professional ATSP Asked to see patient
Commonly used in on-call situations (e.g. “ATSP: reduced urine output”) Auto/allo SCT Autologous/allogenic stem cell transplant BIBA Brought in by ambulance
Used in ED to indicate the patient was brought to the department by ambulance instead of via the waiting room. BNO Bowels not open(ed) CPN Community psychiatric nurse DNACPR/DNR/DNAR Do not attempt CPR/Do not resuscitate/Do not attempt resuscitation Ddx Differential diagnoses DNA Did not attend DOLS Deprivation of liberty safeguards D&V Diarrhoea & vomiting EDD Estimated date of discharge EUA Examination under anaesthesia FAST Face arms speech test FFP Fresh frozen plasma GA General anaesthetic HAS Human albumin solution HCA Healthcare assistant HRT Hormone replacement therapy IVF Intravenous fluids IVI Intravenous infusion Ix Investigations LA Local anaesthetic LPA Lasting power of attorney MCA Mental capacity act MDT Multidisciplinary team
This could refer to the ward team (an MDT consisting of doctors, nursing staff, and allied health professionals) or a cancer MDT meeting (e.g., the upper GI MDT) MFFD Medically fit for discharge MHA Mental health act MOCA Montreal cognitive assessment MRSA Methicillin-resistant Staphylococcus aureus NAI Non-accidental injury NBM Nil by mouth NEWS National early warning score NOF Neck of femur fracture #NOK Next of kin OT Occupational therapist / occupational therapy POA Power of attorney POC Package of care POP Plaster of paris PT Physiotherapist/physiotherapy PU Passed urine ROSC Return of spontaneous circulation SLT/SALT Speech (and) language therapist SOB(OE) Shortness of breath (on exertion) TCI To come in
Commonly used in patient lists to indicate which patients are on their way to hospital (e.g. following a GP referral) TTO/TTA To-take-out/To-take-away
This refers to medications the patient is discharged with VTE Venous thromboembolism # Fracture ΔΔ Used to indicate differential diagnoses Δ Used to indicate the current diagnosis