Medical Documentation Abbreviations
79 abbreviations · part of Medical Abbreviations
Medical documentation abbreviations structure the notes clinicians write every day: history and physicals, SOAP progress notes, handoff reports, discharge summaries and order records. They range from note headings (HPI, ROS, PMH, A/P) and the "x" family of shorthand (Hx, Dx, Tx, Sx) to social history terms (ETOH, PPD) and handoff tools (SBAR, I-PASS). Several, such as D/C, are on the ISMP list of error-prone abbreviations because they can mean opposite things, so many hospitals require them to be written out in orders.
| Abbreviation | Stands for | Description |
|---|---|---|
| A/P | Assessment and plan | Final section of a progress note or H&P containing the clinician's interpretation of the problems and what will be done for each. |
| ADT | Admission, discharge, transfer | Hospital system events and records that track patient movement: admitting a patient, transferring between units and discharging. |
| AVS | After-visit summary | Patient-facing printout or portal document given after an appointment or discharge, listing diagnoses, medications, instructions, upcoming tests and follow-up… |
| Bx | Biopsy | Shorthand for biopsy, the removal of tissue for examination under a microscope. |
| CBE | Charting by exception | Documentation system in which nurses chart in detail only findings that differ from predefined normal standards, relying on flowsheets and protocols for everything else. |
| CC | Chief complaint | Main reason the patient seeks care, ideally recorded in the patient's own words, such as "chest pain" or "can't catch my breath". |
| CDI | Clinical documentation improvement | Hospital program in which specialists review charts and query physicians so that documentation accurately reflects patient severity, diagnoses and complications. |
| CPOE | Computerized provider order entry | System in which clinicians enter medication, laboratory, imaging and other orders directly into the electronic record instead of writing them on paper. |
| CTM | Continue to monitor | Plan phrase indicating no active intervention is needed now but the finding or condition will be watched, as in "CTM I&O" or "CTM for signs of bleeding". |
| Cx | Culture | Shorthand for a microbiological culture, in which a sample is incubated to grow and identify bacteria or fungi and test antibiotic sensitivity. |
| D/C | Discharge | Release of a patient from the hospital, emergency department, program or service, used as a noun or verb in notes and orders such as "D/C home" or "D/C planning". |
| DAR | Data, Action, Response | Focus-charting format in nursing in which each entry names a focus, such as a symptom, event or behavior, then records supporting data, the nursing action taken and the… |
| DDx | Differential diagnosis | List of possible conditions that could explain the patient's symptoms, usually ranked by likelihood or danger, which guides testing until one diagnosis is confirmed. |
| DOE | Dyspnea on exertion | Breathlessness that appears with physical activity, such as climbing stairs or walking a set distance. |
| DS | Discharge summary | Document summarizing a hospital stay for the next caregiver: reason for admission, key findings, procedures, hospital course, condition at discharge, medications… |
| Dx | Diagnosis | Shorthand for diagnosis, the identification of the disease or condition causing the patient's problem. |
| EHR | Electronic health record | Digital record of a patient's health information designed to be shared across providers and organizations, including notes, results, medications, allergies, imaging and… |
| EMR | Electronic medical record | Digital version of a patient's chart within one practice or organization, containing notes, orders and results. |
| ETOH | Ethanol (alcohol) | Shorthand for alcohol in social histories, toxicology results and assessments, as in "ETOH use", "ETOH withdrawal" or "ETOH level". |
| f/u | Follow-up | Planned future visit, call, test or review to check progress or results, used in plans and discharge instructions, as in "f/u with PCP in 1 week". |
| FH | Family history | Section of the history recording health problems in blood relatives, especially first-degree relatives (parents, siblings and children), and the ages at which they… |
| Fx | Fracture | Shorthand for a broken bone, used with the bone name and type, as in "R distal radius Fx" or "hip Fx". |
| H&P | History and physical | Comprehensive admission note documenting the chief complaint, HPI, past history, medications, allergies, family and social history, review of systems, physical exam and… |
| HD | Hospital day | Count of days since admission, used in progress notes and handoffs, as in "HD 4". |
| HIM | Health information management | Hospital department responsible for medical records: maintaining, coding, releasing and protecting patient information, and tracking incomplete or unsigned documentation. |
| HOPI | History of presenting illness | British and Commonwealth heading for the detailed account of the patient's current complaint, equivalent to the American HPI. |
| HPI | History of present illness | Narrative section of a medical history describing the current problem in chronological order: onset, location, character, severity, timing, context, aggravating and… |
| Hx | History | Shorthand for history, used alone or in combinations such as "Hx of" (has a history of) and in headings like PMHx and FHx. |
| I-PASS | Illness severity, Patient summary, Action list, Situation awareness and contingency planning, Synthesis by receiver | Structured patient handoff tool used between physician teams and nurses at shift change. |
| ICE | Ideas, concerns, expectations | Consultation framework in which the clinician asks what the patient thinks is wrong, what worries them and what they hope will happen. |
| Imp | Impression | Heading for the clinician's summary interpretation of findings, used in radiology reports, specialist consults and some progress notes. |
| ISBAR | Identify, Situation, Background, Assessment, Recommendation | Handoff format that adds identification of the speaker, patient and location before the SBAR elements. |
| IVDA | Intravenous drug abuse | Older charting term for injecting drugs into a vein, now discouraged in favor of neutral terms such as injection drug use or people who inject drugs. |
| IVDU | Intravenous drug use | Charting term for injecting drugs into a vein, recorded in social history because it affects risk of endocarditis, hepatitis C, HIV, skin abscesses and overdose. |
| Ix | Investigations | British and Commonwealth shorthand for diagnostic tests such as blood tests, imaging and ECGs, used in plans and referral letters. |
| LOS | Length of stay | Number of days a patient remains in hospital from admission to discharge. |
| MDM | Medical decision making | Part of a note showing the clinician's reasoning: the number and complexity of problems, the data reviewed or ordered, and the risk of management choices. |
| MRN | Medical record number | Unique identifier assigned by a hospital or health system to each patient, used on wristbands, labels, orders and records. |
| Mx | Management | Shorthand for management, the plan for treating and monitoring a condition. |
| N/V/D | Nausea, vomiting, diarrhea | Cluster of gastrointestinal symptoms recorded together in triage notes, histories and nursing assessments, typical of gastroenteritis, food poisoning and medication… |
| NFA | No further action | British police and prosecution decision to close a case without charging a suspect, for example because of insufficient evidence. |
| NOK | Next of kin | Closest relatives of a service member, recorded on the DD Form 93 Record of Emergency Data and notified in person if the member is killed, missing or seriously injured. |
| NOS | Not otherwise specified | Coding and diagnostic qualifier meaning a condition is documented without further detail that would allow a more specific category. |
| O/E | On examination | British and Commonwealth notation introducing physical examination findings in clinical notes and referral letters. |
| OLDCARTS | Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity | Mnemonic for the questions that build a history of present illness. |
| PC | Presenting complaint | British and Commonwealth heading for the main problem that brought the patient to medical attention, equivalent to the American chief complaint. |
| PCP | Primary care provider | Clinician who provides a patient's ongoing first-contact care, coordinates referrals and manages chronic conditions; may be a physician, nurse practitioner or physician… |
| PE | Physical examination | Section of a note recording the examiner's findings by body system, from vital signs and general appearance to specific maneuvers. |
| PIE | Problem, Intervention, Evaluation | Nursing charting method that groups notes under numbered problems, recording the intervention for each problem and an evaluation of the outcome. |
| pk-yr | Pack-year | Measure of lifetime cigarette exposure, calculated as packs smoked per day multiplied by years of smoking; 1 pack a day for 20 years equals 20 pack-years. |
| PMH | Past medical history | Section of the history listing chronic illnesses, past serious illnesses, hospitalizations and significant diagnoses. |
| PN | Progress note | Daily or periodic note documenting a patient's status, new findings, assessment and plan during a hospital stay or course of treatment. |
| POA | Present on admission | Indicator on US inpatient claims showing whether each diagnosis existed when the order for inpatient admission occurred. |
| POC | Plan of care | Documented set of goals, interventions and expected outcomes for a patient, developed by the care team and updated as the patient changes. |
| PPD | Packs per day | Measure of cigarette smoking recorded in social histories, such as "1 PPD", meaning about 20 cigarettes a day. |
| ppx | Prophylaxis | Preventive treatment given to stop a condition from developing, such as DVT ppx, GI ppx or antibiotic ppx before surgery. |
| PSH | Past surgical history | Section of the history listing previous operations and invasive procedures, ideally with dates and complications. |
| Pt | Patient | The person receiving care, written "pt" or "Pt" throughout nursing notes, orders and messages to save time. |
| PTA | Prior to admission | Phrase describing events, symptoms or medications from before the patient was admitted to hospital, especially the home medication list. |
| PWID | People who inject drugs | Person-first public health term for individuals who inject substances such as opioids or stimulants. |
| Px | Prognosis | Shorthand for prognosis, the expected course and outcome of a disease. |
| R/O | Rule out | Indicates a condition being actively investigated so it can be confirmed or excluded, as in "R/O MI" or "R/O sepsis". |
| ROS | Review of systems | Structured series of questions about symptoms in each body system, such as constitutional, cardiovascular, respiratory and gastrointestinal, to catch problems the… |
| RTC | Return to clinic | Instruction for when the patient should come back, as in "RTC 3 months" or "RTC PRN". |
| SBAR | Situation, Background, Assessment, Recommendation | Structured communication tool for handoffs and urgent calls, giving the current problem, relevant context, the speaker's assessment and a clear request. |
| SH | Social history | Section of the history covering tobacco, alcohol and drug use, occupation, living situation, relationships, sexual history, travel, exercise and other factors that… |
| SOAP | Subjective, Objective, Assessment, Plan | Four-part structure for clinical progress notes: what the patient reports, measurable findings such as vital signs, exam and test results, the clinician's… |
| SOAPIE | Subjective, Objective, Assessment, Plan, Intervention, Evaluation | Nursing variant of the SOAP note that adds the care actually given and the patient's response to it. |
| SOB | Shortness of breath | Symptom of difficult or uncomfortable breathing, recorded in chief complaints, triage notes and review of systems. |
| Sx | Symptoms | Shorthand for symptoms, the subjective experiences reported by the patient, such as pain, nausea or fatigue, as opposed to signs found on examination. |
| TO | Telephone order | Order given by a prescriber over the phone to a licensed nurse or pharmacist, who enters it in the record and reads it back. |
| TORB | Telephone order read back | Charting tag indicating that a telephone order was repeated back to the prescriber and confirmed. |
| Tx | Treatment | Shorthand for treatment or therapy, used in plans, orders and notes to describe what was given or recommended. |
| UTD | Up to date | Notation that the patient's immunizations or screenings are current, recorded in pediatric visits, triage and preventive care notes. |
| VO | Verbal order | Order given aloud by a prescriber, usually in person during emergencies or procedures, and recorded by the nurse or other licensed staff. |
| VORB | Verbal order read back | Documentation tag showing that a verbal order was repeated to the prescriber and confirmed before being carried out. |
| w/u | Workup | Set of tests, imaging and consultations used to investigate a symptom or suspected condition, as in "syncope w/u" or "anemia w/u". |
| WDWN | Well-developed, well-nourished | General appearance phrase at the start of a physical exam noting normal body build and nutritional state. |
| y/o | Years old | Age notation used in the opening line of notes and presentations, as in "67 y/o male". |
More medical abbreviations
- Anatomy Abbreviations (70)
- Anesthesia Abbreviations (34)
- Cardiology Abbreviations (229)
- Dermatology Abbreviations (52)
- Drug Abbreviations (170)
- Drug Class Abbreviations (113)
- Emergency Medicine Abbreviations (97)
- Endocrinology & Diabetes Abbreviations (64)
- Gastroenterology Abbreviations (85)
- Health Insurance Abbreviations (107)
- Healthcare Credential Abbreviations (122)
- Hematology and Oncology Abbreviations (144)
- Hospital Abbreviations (89)
- Infectious Disease Abbreviations (92)
- Laboratory Test Abbreviations (135)
- Medical Imaging Abbreviations (58)
- Medical Research Abbreviations (94)
- Medical Specialty Abbreviations (47)
- Medication Route Abbreviations (41)
- Mental Health & Psychiatry Abbreviations (100)
- Musculoskeletal & Rheumatology Abbreviations (71)
- Nephrology & Urology Abbreviations (71)
- Neurology Abbreviations (131)
- Nursing Abbreviations (90)
- Obstetrics & Gynecology Abbreviations (89)
- Ophthalmology & ENT Abbreviations (74)
- Patient Assessment Abbreviations (65)
- Pediatric & Neonatal Abbreviations (51)
- Pharmacology Abbreviations (36)
- Pharmacy Abbreviations (134)
- Prescription Abbreviations (77)
- Rehabilitation Abbreviations (98)
- Respiratory Abbreviations (109)
- Surgical Abbreviations (51)