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
> greater than
< less than