Common abbreviations used in personal injury medical records

Medical records play a critical role in every personal injury case. You may find, however, that you have trouble deciphering the information contained in your medical records because doctors, nurses and other medical professionals speak in a shorthand language all their own. Medical records are replete with abbreviations, many of which have no real connection to the English language words they purport to abbreviate. For example, “c” is an abbreviation of the Latin word “cum,” which means “with.” The word “with” is also abbreviated as “w/,” sometimes in the same paragraph as “c.” Two other “c” abbreviations that you will see often are “cc” and “c/o.” “CC” means “chief complaint,” which often is the doctor’s conclusion as to the patient’s main problem; “c/o,” on the other hand, means “complains of,” which is a statement reciting what the patient told the doctor about the patient’s ailments. Unless you and your personal injury lawyer know a number of medical abbreviations, you are likely to miss an important point in your medical records, or possibly even an error in your medical records, that may be helpful in proving your injury claim.

Eight essential medical abbreviations to know in a personal injury case

You and your personal injury lawyer must recognize the following eight abbreviations, or you run the risk of being unpleasantly surprised by the defense in your injury accident lawsuit. For example, a smart injury lawyer knows that “BP > normal” does not mean “normal blood pressure, and that “ETOH” means his client had been drinking before the accident.

AMA         against medical advice
DNKA      did not keep appointment
ETOH      ethyl alcohol [indicates liquor consumption]
GSW         gunshot wound
N.A.D.      no acute distress
OD             overdose
STD          sexually transmitted disease
>                greater than
<                less than

Other abbreviations that commonly appear in personal injury medical records

Keep this list of common abbreviations close at hand when you review your medical records:

abd         abdomen or abdominal
ad lib     as much as needed or desired
ADL       activities of daily living
adm       admission
a/o         alert and orientated
ASA       aspirin

BCP      birth control pills
BE         barium enema
bid.       two times a day
b.i.d.     two times a day
BK        below the knee
BM       bowel movement
BP        blood pressure
BR        bed rest – or bathroom

c                with
CAT         Computerized Axial Tomography
CBC         complete blood count
CC – or cc     chief complaint
CICU        coronary intensive care unit
CNS          central nervous system
c/o            complains of
cpd            compound
CPR           cardiopulmonary resuscitation
c-spine     cervical spine
CT             CAT scan
CXR          chest X-ray

d/c            discontinue
D/C – or dc     discharge
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
ER          emergency room

Fem       femoral
FH          family history
FHR       fetal heart rate
FHx       family history
fu – or F/U      follow up
Fx          fracture
Fx dis       fracture dislocation

GP            general practitioner

H&P          history and physical
HA – or h/a     headache
HBP          high blood pressure
HEENT   head, ears, eyes, nose, throat
HPI          history of present illness
hr              hour
HR            heart rate
Hx             history

I&D          incision and drainage
ICU          intensive care unit
ICCU       intensive coronary-care unit
IM            intramuscular
IV             intravenous

KLS         kidney, liver, spleen

L              left
L              lumbar
Lab         laboratory
LE’s        lower extremities
LOC        level of consciousness — or loss of consciousness
M.E.        medical examiner
MAE       moving all extremities
MICU     medical intensive care unit – or mobile intensive care unit
MVA       motor vehicle accident

NEU        neurological
NKA        no known allergies
nl              normal limits
NS            neurosurgery
N/V         nausea and vomiting
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
Occ         occasional
OR          operating room
ORIF      open reduction & internal fixation
Ortho     orthopedic
OT          occupational therapy
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
pt              patient
PT            physical therapy
PTA         prior to admission
PX            prognosis

q.d.           every day
q.h.           every hour
qid or q.i.d.    4 times a day

R                 right
RN             registered nurse
R/O           rule out
ROM         range of motion
RR             recovery room

s                  without
SLR           straight leg raising
S/P            status post
STAT       immediately
surg           surgery
SX              symptoms

tid or t.i.d.     3 times a day
TMJ                 temporomandibular joint
TPR                 temperature, pulse, and respiration
TX or Tx        treatment

Ua             urinalysis
U.E.’s       upper extremities

V.O.          verbal order

W               white
w/               with
WNLl        within normal limits