Common abbreviations and symbols in medical records

It is virtually impossible for a Personal Injury Attorney to handle Personal Injury cases effectively if he or she does not know how to analyze and understand a client’s medical records. Insurance companies and defense law Firms have trained personnel, including nurses, who know how to read and decipher medical reports, hospital records, and laboratory results. If a plaintiff’s Lawyer tries to negotiate a Personal Injury settlement without understanding the exact nature of his or her client’s injuries, they may settle the case for a fraction of its value.

Personal Injury Lawyers must know the most important medical terms and abbreviations. The following abbreviations and code symbols are frequently used in medical reports, hospital records, nurses’ notes, and other medical documents. An experienced Personal Injury Lawyer knows it is imperative to understand the meaning of these abbreviations and symbols because they refer to actual conditions of their clients.

For example, a reference to “ETOH” may mean that the patient had consumed alcohol and may have been under the influence of intoxicating beverages. Such a reference could be extremely important in a Personal Injury case. Failure to recognize a reference to alcohol consumption could make a difference in the value of the settlement and would also be fatal if an Attorney learned it for the first time at Trial.

Many medical reports indicate that injuries are “secondary to MVA.” Such a reference indicates the doctor’s impression that the injuries were caused by the automobile collision, addressing the major question of causation. If such a reference is indicated in the hospital record, it may be possible to prove your case, if it is a small one, by admission of the certified hospital record. Such evidence avoids the need for expensive testimony from a physician.

Another abbreviation is “DNKA.” This symbol is often noted in physical therapy reports and can be fatal to the settlement of your case. It means that the patient did not keep the appointment and such a reference is often used by defense Attorneys at Trial indicating that the plaintiff failed to mitigate damages by not keeping appointments with either the doctor or the physical therapist.

The list below contains some of the most frequently used abbreviations in medical records:

abdabdomen or abdominal
ad libas much as needed or desired
ADLactivities of daily living
admadmission
AKabove the knee
AMAagainst medical advice
ambambulate
a/oalert and orientated
ARDSadult respiratory distress syndrome
AROMartificial rupture of the membranes
ASAaspirin
BCPbirth control pills
BEbarium enema
bid, b.i.d.two times a day
BKbelow the knee
BMblack male or bowel movement
BPblood pressure
BRbed rest or bathroom
cwith [used frequently]
CATComputerized Axial Tomography
C&SCulture and sensitivities
CBCcomplete blood count
CC or ccchief complaint [used frequently]
CICUcoronary intensive care unit
CNScentral nervous system
c/ocomplain of [used frequently]
cpd fxcompound fracture [more serious than a normal fracture]
CPRcardiopulmonary resuscitation
c-spinecervical spine
CTCAT scan
CXRchest X-ray
d/cdiscontinue
D/C, DCdischarge
DNKAdid not keep appointment [very important]
DTRdeep tendon reflexes
dxdiagnosis
EBLestimated blood loss
ECGelectrocardiogram
EDCestimated date of confinement
EEGelectroencephalogram
EKGelectrocardiogram
EMSemergency medical service
EOAoral airway
Epiepidural
ERemergency room
ETOHethyl alcohol [important—indicates alcohol consumption]
Feiron
Femfemoral
FHfamily history
FHRfetal heart rate
FHTfetal heart tone
FHMfetal heart monitor
FHxfamily history
FOBfoot of bed
Lu., F/Ufollow up
Fxfracture
Fx disfracture dislocation/dislocated
GPgeneral practitioner
GSWgunshot wound
GYNgynecology
H&Phistory and physical
HA, H/Aheadache
HBPhigh blood pressure
HEENThead, ears, eyes, nose, throat
HOBhead of bed
HPIhistory of present illness
hrhour
HRheart rate
Hxhistory
I&Dincision and drainage
ICCUintensive coronary-care unit [illustrates concern about heart problems]
IMintramuscular
IUDintrauterine device
IVintravenous
KLSkidney, liver, spleen [any Injury to these organs is significant]
Lleft
Llumbar
Lablaboratory
LE’slower extremities
LMPlast menstrual period
LOClevel of consciousness or loss of consciousness [very important]
Mmurmur
M.E.medical examiner
MAEmoving all extremities
MCLmidclavicular line
med(s)medications
MICUmedical intensive care unit, or mobile intensive care unit
MVAmotor vehicle accident [used frequently]
N.A.D.no acute distress
NEU, Neuneurological
NKAno known allergies
nlnormal limits
NSneurosurgery
N/V, N&Vnausea and vomiting
N/V/Dnausea, vomiting, diarrhea
O.D.right eye
O.S.left eye
O.U.both eyes
OAosteoarthritis
OBobstetrics
Occoccasional
ODoverdose
ORoperating room
ORIFopen reduction & internal fixation
Orthoorthopedic
OT, O/Toccupational therapy
PEphysical examination
PGpregnant
PHpast history
PIpresent illness
PMHprior medical history
poby mouth
P.O.phone order
post-oppost operative pre-op pre-operative
PRNas required or as needed [used frequently]
ptpatient
PTphysical therapy
PTAprior to admission
PXprognosis
q.a.m.every morning
q.d.every day
q.h.every hour q.i.d. or QID 4 times a day
Rright
RNregistered nurse
R/Orule out
ROMrange of motion or rupture of membranes
RRrecovery room
swithout
SLRstraight leg raising
S/Pstatus post
STATimmediately
STDsexually transmitted disease
surgsurgery
SX, Sxsymptoms
tic, t.i.d.3 times a day
TMJtemporomandibular joint
TPRtemperature, pulse & respiration
TX, Txtreatment
Uaurinalysis
UCHDusual childhood diseases
U.E.’supper extremities
V.O.verbal order
Wwhite
W/, w/with
WNL, wnlwithin normal limits
xtimes
increase
decrease
>greater than
<less than