A.B.C.D.E: Acronyms Become Clearer Due to Experience

Published December 2023 in the ISHA Voice

By Jennifer Furlane and Roger Reeter

Jennifer and Roger are members of the Medical Practice Issues Committee.

Medical abbreviations and acronyms can sometimes be difficult to understand for the new graduate or those not currently working in healthcare centers. Sometimes vague or new acronyms can be challenging to medical professionals far into their career as well!  In the past, medical notes were written by hand and space and time were limited. Although our time is often still very limited, electronic medical records (EMRs) have hopefully made it easier to understand other professional’s notes now that they are entered digitally, typed, or dictated; however, some medical professionals may still prefer to hand-write notes, or work on forms for ease or speed in different situations. It is not uncommon to find medical shorthand used in typed messages as well. In discharge summary reports written by physicians, almost one third of the abbreviated terms were found to be ambiguous or unclear (Holper, 2020). That is why it is wise to gain experience reviewing acronyms in context to aid understanding.

The authors believe a quick introduction to some common abbreviations, symbols, and medical shorthand may help ISHA members unfamiliar with this writing. This article is not intended to be all-encompassing or an endorsement to use these abbreviations, but to help your understanding if you should come across them in chart reviews. In the experience of these authors of a combined 33 years we have listed selections of abbreviations often used in reports and charts.

DIAGNOSES:

Often you may see common diseases listed in the medical chart; however, you may be confused by the abbreviations here is a list of common diagnosis often seen.

•AKA: Above the knee amputation

•ALS: Amyotrophic lateral sclerosis

•AMS: Altered mental status

•Afib: Atrial fibrillation

•ARF: Acute renal failure OR acute respiratory failure

•BKA: Below the knee amputation

•CABG: Coronary artery bypass graft

•CAD: Coronary artery disease

•CHF: Congestive heart failure

•CHI: Closed Head Injury

•COPD: Chronic obstructive pulmonary disease

•CVA: Cerebrovascular accident

•CHF: Congestive heart failure

•DM: Diabetes mellitus

•DVT: Deep vein thrombosis

•Dx: Diagnosis

•ESRD: End stage renal disease

•EtOH: Ethyl Alcohol

•Fx: Fracture

•GBS: Guillain Barre Syndrome

•GERD: Gastroesophageal reflux disease

•GSW: Gunshot Wound

•HTN: Hypertension

•HL/HOH: Hearing loss/ hard of hearing

•LOC: Loss of consciousness

•LVAD: Left ventricular assist device

•MI: Myocardial infarction

•MRSA: Methicillin-Resistant Staphylococcus aureus

•MVA: Motor vehicle accident

•NKA: No known Allergies

•NSC(L)C: Non-squamous cell (lung) carcinoma

•PD: Parkinson’s Disease

•PE: Pulmonary embolism

•PNA: Pneumonia

•PVD: Peripheral vascular disease

•SCC: Squamous cell carcinoma

•STEMI: Segment Elevation Myocardial Infarction

•TBI: Traumatic brain injury

•URI: Upper respiratory infection

•UTI: Urinary tract infection

UNITS:

Hospital units and other medical facilities often are referred to by their abbreviations. Your students and clients may have had a stay on one of these units. Here is a list of common abbreviations for hospital units and medical facilities:

•AR: Acute rehab

•CCU: Coronary care unit

•HAU: High acuity unit

•ICCU: Intensive coronary care unit

•ICU:  Intensive care unit

•LTACH: Long Term Acute Care Hospital

•MICU: Medical intensive care unit

•NICU: Neonatal Intensive Care Unit

•OOH: Out of hospital

•OSH: Outside hospital

•PICU: Pulmonary Intensive Care Unit

•SNF: Skilled Nursing Facility

PULMONARY:

Sometimes a string of numbers only becomes useful in context. For example, the phrase 12/40/5/450. Without any labels these numbers could mean a lot of things; however, with some experience with common vent settings each number there represents a fixed attribute to a mechanical ventilator. Respectively, 12 breaths per minute, 40% FiO2 (fraction of inspired oxygen), PEEP of 5 (Positive end expiratory pressure), and a 450mL tidal volume.

•A/C: Assist Control

•ABG: Arterial blood gas

•CMV: Control Mode Ventilation

•CPAP: Continuous Positive Airway Pressure

•CXR: Chest X-ray

•ECMO: Extracorporeal membrane oxygenation

•EF: Ejection fraction

•LLL: Left Lower Lobe (lung)

•O2: Oxygen

•PS / PSV: Pressure support ventilation

•RLL: Right Lower Lobe (lung)

•SIMV: Synchronous Intermittent Mandatory Ventilation

•SOB: Shortness of breath

•Sux: Suction

•TP: T-piece

•TC: Trach collar

•WOB: Work of breathing

REHABILITATION:

Many patients go through either pediatric or adult rehabilitation. Common terms especially in this area can be confusing if unknown. The following is a list of common rehabilitation-related abbreviations:

•ADL: Activities of daily living

•b/l: Bilateral

•BID: Twice a day

•BLE: Bilateral lower extremity

•BUE: Bilateral upper extremity

•CSA: Clinical signs of aspiration

•CSE: Clinical Swallow Evaluation

•DNT: Did not test

•EOB: Edge of bed

•EMST: Expiratory muscle strength training

•FIM: Functional independence level

•GOC: Goals of care

•GCS: Glasgow Coma Scale

•G/JT: Gastrojejunal (GJ) tube

•H&P: History and physical

•h/o: History of

•HEP: Home exercise program

•HOB: Head of bed

•HOH: Hand over hand

•Hx: History

•Ⓘ: Independent

•ICF: International Classification of Functioning, Disability and Health

•IDDSI: International Dysphagia Diet Standardisation Initiative

•LOA: Level of assist

•LOS: Length of stay

•LRD: Least restrictive diet

•LRE: Least restrictive environment

•MAE: Moves all extremities

•Mod I: Modified Independent

•NMES: Neuromuscular electronic stimulation

•NG(T): Nasogastric tube

•OME: Oral Musculature (motor) examination

•PEG: Percutaneous endoscopic gastrostomy

•PMHx: Past medical history

•TF: Tube feeds

•TIA: Transient ischemic attack

•WFL: Within functional limits

•WNL: Within normal limits

HANDWRITTEN NOTES AND MISCELLANEA:

Shorthand is also used especially in handwritten notes. The shorthand can be the most confusing as a new clinician. The following list concludes our review with any remaining abbreviations we felt may be useful:

•2/2: secondary to

•Ⓐ: Assist

•/a: before

•/c: with (can also be w/)

•/p: after

•/s: without (can also be w/o)

•A.c.: before meals (Latin ante cibum)

•abx:antibiotics

•AMA: against medical advice

•BUN: Blood urea nitrogen

•CT: Computerized tomography

•℅: complains of

•D/C: Discontinue

•DC: Discharge

•DNR: Do not resuscitate

•f/u: Follow up

•HENMT: Head Ears Nose Mouth Tongue

•HGB: Hemoglobin

•Noc: nocturnal

•N.p.o.: Nothing by mouth (Latin: nil per os)

•P.c.: after eating (Latin post cibum)

•PCT: Patient Care Technician

•PICC: Peripherally inserted central catheter

•Pmsx: Past surgical history

•P.o.: By mouth

•PPN: Partial parenteral nutrition

•P.r.n: as needed (Latin pro re nata)

•Pt: Patient

•Q.i.d.: Four times a day

•RBC: Red Blood cell count

•RCP / RT: Respiratory care practitioner / Respiratory therapist

•Rx: Prescription

•s/p: Status post

•s/s: Signs and symptoms

•Sx: Surgery OR symptom

•T.i.d.: Three times daily

•TPN: Total parenteral nutrition

•Trach: Tracheostomy or trach tube

•Tx: treatment OR therapy OR transplant

•U.d.: as directed (Latin ut dictum)

•WBC: White blood cell count

We hope we have helped you navigate these common medical abbreviations and terms that we may use as speech-language pathologists or audiologists.  Learning these terms will make understanding charts you receive easier and hopefully help you explain some of these terms to your student/client and their families when needed. You can also find more lists of common medical abbreviations at: https://www.medabbrev.com.

Another helpful resource is the list of error prone abbreviations that the ISMP (Institute for Safe Medical Practice) warns about. For example, the abbreviation Qn would indicate “every night” however especially in handwritten notes the n could be misidentified as an h and interpreted incorrectly as “every hour.” 

References:

Holper S, Barmanray R, Colman B, Yates CJ, Liew D, Smallwood D. Ambiguous medical abbreviation study: challenges and opportunities. Internal Medicine Journal 2020; 50: 1073–8.

Institute for Safe Medication Practices (ISMP). ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. ISMP; 2021.

Jennifer Furlane MS, CCC-SLP is a member of the Medical Practice Issues Committee. She has 22 years of experience working with pediatrics and adults in acute care, inpatient rehabilitation, outpatient settings and a mobile swallow study unit. Jennifer has special interests working with patients with dysphagia, head and neck cancer, and voice diagnosis.

Roger Reeter M.A., CCC-SLP is a member of the Medical Practice Issues Committee and the Legislative and Regulatory Affairs Committee. He has been volunteering for ISHA since he was an undergrad student. He has experience at the long-term acute care RML Specialty Hospital since 2013, specializing in communication, swallowing, and trach and vent care in a wide variety of medically complex patients. He finds working with patients and their families very rewarding. He also enjoys teaching as an Adjunct Professor at Lewis University.