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:

abd	abdomen or abdominal
ad lib	as much as needed or desired
ADL	activities of daily living
adm	admission
AK	above the knee
AMA	against medical advice
amb	ambulate
a/o	alert and orientated
ARDS	adult respiratory distress syndrome
AROM	artificial rupture of the membranes
ASA	aspirin
BCP	birth control pills
BE	barium enema
bid, b.i.d.	two times a day
BK	below the knee
BM	black male or bowel movement
BP	blood pressure
BR	bed rest or bathroom
c	with [used frequently]
CAT	Computerized Axial Tomography
C&S	Culture and sensitivities
CBC	complete blood count
CC or cc	chief complaint [used frequently]
CICU	coronary intensive care unit
CNS	central nervous system
c/o	complain of [used frequently]
cpd fx	compound fracture [more serious than a normal fracture]
CPR	cardiopulmonary resuscitation
c-spine	cervical spine
CT	CAT scan
CXR	chest X-ray
d/c	discontinue
D/C, DC	discharge
DNKA	did not keep appointment [very important]
DTR	deep tendon reflexes
dx	diagnosis
EBL	estimated blood loss
ECG	electrocardiogram
EDC	estimated date of confinement
EEG	electroencephalogram
EKG	electrocardiogram
EMS	emergency medical service
EOA	oral airway
Epi	epidural
ER	emergency room
ETOH	ethyl alcohol [important—indicates alcohol consumption]
Fe	iron
Fem	femoral
FH	family history
FHR	fetal heart rate
FHT	fetal heart tone
FHM	fetal heart monitor
FHx	family history
FOB	foot of bed
Lu., F/U	follow up
Fx	fracture
Fx dis	fracture dislocation/dislocated
GP	general practitioner
GSW	gunshot wound
GYN	gynecology
H&P	history and physical
HA, H/A	headache
HBP	high blood pressure
HEENT	head, ears, eyes, nose, throat
HOB	head of bed
HPI	history of present illness
hr	hour
HR	heart rate
Hx	history
I&D	incision and drainage
ICCU	intensive coronary-care unit [illustrates concern about heart problems]
IM	intramuscular
IUD	intrauterine device
IV	intravenous
KLS	kidney, liver, spleen [any injury to these organs is significant]
L	left
L	lumbar
Lab	laboratory
LE’s	lower extremities
LMP	last menstrual period
LOC	level of consciousness or loss of consciousness [very important]
M	murmur
M.E.	medical examiner
MAE	moving all extremities
MCL	midclavicular line
med(s)	medications
MICU	medical intensive care unit, or mobile intensive care unit
MVA	motor vehicle accident [used frequently]
N.A.D.	no acute distress
NEU, Neu	neurological
NKA	no known allergies
nl	normal limits
NS	neurosurgery
N/V, N&V	nausea and vomiting
N/V/D	nausea, vomiting, diarrhea
O.D.	right eye
O.S.	left eye
O.U.	both eyes
OA	osteoarthritis
OB	obstetrics
Occ	occasional
OD	overdose
OR	operating room
ORIF	open reduction & internal fixation
Ortho	orthopedic
OT, O/T	occupational therapy
PE	physical examination
PG	pregnant
PH	past history
PI	present illness
PMH	prior medical history
po	by mouth
P.O.	phone order
post-op	post operative pre-op pre-operative
PRN	as required or as needed [used frequently]
pt	patient
PT	physical therapy
PTA	prior to admission
PX	prognosis
q.a.m.	every morning
q.d.	every day
q.h.	every hour q.i.d. or QID 4 times a day
R	right
RN	registered nurse
R/O	rule out
ROM	range of motion or rupture of membranes
RR	recovery room
s	without
SLR	straight leg raising
S/P	status post
STAT	immediately
STD	sexually transmitted disease
surg	surgery
SX, Sx	symptoms
tic, t.i.d.	3 times a day
TMJ	temporomandibular joint
TPR	temperature, pulse & respiration
TX, Tx	treatment
Ua	urinalysis
UCHD	usual childhood diseases
U.E.’s	upper extremities
V.O.	verbal order
W	white
W/, w/	with
WNL, wnl	within normal limits
x	times
↑	increase
↓	decrease
>	greater than
<	less than