Abbreviations Used in Medical Records

Abbreviations are commonly used in medical records to save time and space when writing medical information in a patient's medical record, file or for prescriptions. Many medical conditions and drugs have long complicated names that would take time to completely write on a patient's chart or script if abbreviations were not used. Most medical abbreviations used are universally understood by doctors, nurses and other medical professionals.

Uses

• The use of abbreviations in patient care documentation, such as a hospital chart, typically makes a health professional' s job more efficient. Medical facilities, such as a hospital, may adopt their own specific list of abbreviations that are not used elsewhere. Most abbreviations represent acceptable medical terms used by a particular facility. This means that a health professional may only need to become familiar with one set of abbreviations and then learn variations that may be encountered at different locations.

Abbreviation Errors

• Errors with abbreviations for certain medical terms, conditions and drugs can lead to various types of medical errors. Medical errors are typically caused by illegible writing and misrepresentations of some types of abbreviations when providing treatments or filling a prescription. As a result health care agencies, such as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO, have required hospitals and other medical facilities to create a list of unacceptable abbreviations.

Unacceptable Abbreviations

• Medical facilities, such as the Louisiana State Health Sciences Center, have developed guidelines for the use of abbreviations and symbols used in medical records. Many facilities are also discouraging the use of abbreviations in medical records and documentation. Facilities that publish a list of prohibited abbreviations will list the abbreviation that is prohibited, the potential problem with the abbreviation and the preferred term to use in the medical record.

Common Abbreviations

• Common medical abbreviations that are used in medical records include c/o and h/o which indicates "complaining of" and "history of." Another common abbreviation is CHF, which stands for congestive heart failure. Other common abbreviations include DOB (date of Birth), EKG (electrocardiogram), LAC (laceration), V.S. (vital signs) and Pt. (patient).

Abbreviations and Symbols for Drugs

• Information written on a prescription or medicine that was prescribed while in the hospital are found in a patient's medical record. Abbreviations and symbols that are used for certain types of drugs are frequently used by doctors and physicians when providing care to a patient. Health care workers need to have knowledge of the commonly used abbreviations that are used when referring to a specific drug in a patient's medical documentation.

Laws

• Abbreviations that are used in patient medical records may be regulated by state regulations. The state of Missouri has a regulation that mandates how abbreviations are to be used. The regulation states that there should only be one meaning and use for each abbreviation. A legend that provides an explanation for each abbreviation also needs to be made available to all medical professionals. Health care providers are also required to create a list of abbreviations that should not be used in notes, records or other written communication.