What do the medical abbreviations in my patient records mean?

Medical abbreviations in the UK are often used in patient records, communications, and documentation. While these abbreviations are meant to simplify and speed up communication, they can sometimes be confusing for patients. Here, we delve into some of the most common medical abbreviations you may encounter in your medical records, explain their meanings, and offer insights into how the NHS guidelines govern their use.

 

Why are medical abbreviations used?

In healthcare, time is critical, and the need for clear, quick communication between healthcare professionals is paramount. Medical records, prescriptions, and notes are filled with abbreviations to help medical staff convey information efficiently. However, it’s important that these abbreviations do not compromise patient safety or lead to misinterpretation. To mitigate this risk, the NHS has issued guidelines around the usage of abbreviations in medical settings.

The NHS has been clear about the importance of minimising ambiguous abbreviations in patient records. In fact, it has released guidelines recommending the avoidance of certain abbreviations that could lead to errors or confusion.

For example, the abbreviation “IU” (International Unit) could be misinterpreted as “IV” (intravenous), leading to dangerous medication administration errors. The NHS advises healthcare professionals to use full terms when necessary, especially when patient safety could be at risk.

 

NHS guidelines on abbreviations

According to the NHS Digital standards, abbreviations should be:

• Standardised: Avoid using multiple abbreviations for the same term.
• Commonly accepted: Stick to abbreviations that are widely recognised within the healthcare community.
• Used cautiously: In clinical settings where ambiguity can lead to error, use full terms or clarify the abbreviation.
• Monitored: Healthcare providers must regularly review their records to ensure that any abbreviation used is appropriate and understood by the entire medical team.

While these guidelines are in place, it’s still common to see abbreviations in medical documents. If you’re ever unsure about an abbreviation in your own medical records, don’t hesitate to ask your GP to explain it.

 

Common UK medical abbreviations and their meanings

Here’s a list of some frequently used abbreviations you may encounter in your medical records:

1. BP – Blood Pressure
   Measurement of the force of blood against the walls of the arteries.
2. BMI – Body Mass Index
   A measurement used to assess whether a person is underweight, normal weight, overweight, or obese.
3. IV – Intravenous
   Administering fluids or medication directly into a vein.
4. BSL – Blood Sugar Level
   The concentration of glucose in the blood, commonly monitored in patients with diabetes.
5. ECG – Electrocardiogram
   A test that measures the electrical activity of the heart.
6. ECHO – Echocardiogram
   An ultrasound of the heart to evaluate heart function.
7. CT – Computed Tomography
   A type of X-ray that takes detailed cross-sectional images of the body.
8. MRI – Magnetic Resonance Imaging
   A scan that uses magnetic fields to create detailed images of organs and tissues.
9. HbA1c – Hemoglobin A1c
   A blood test used to monitor long-term blood sugar control in diabetics.
10. COPD – Chronic Obstructive Pulmonary Disease
    A lung condition that causes breathing difficulties, typically due to smoking.
11. U&E – Urea and Electrolytes
    A blood test to measure kidney function and electrolyte balance.
12. LFT – Liver Function Test
    A test to assess the health and function of the liver.
13. BUN – Blood Urea Nitrogen
    A test used to measure kidney function.
14. TTE – Transthoracic Echocardiogram
    A non-invasive test that uses sound waves to create a picture of the heart.
15. PRN – Pro Re Nata (as needed)
    A prescription for a medication that is only to be taken when necessary, such as pain relief.
16. DVT – Deep Vein Thrombosis
    A blood clot that forms in a deep vein, usually in the legs.
17. MI – Myocardial Infarction
    The medical term for a heart attack.
18. TIA – Transient Ischemic Attack
    A mini-stroke caused by a temporary reduction in blood supply to part of the brain.
19. CVA – Cerebrovascular Accident
    The medical term for a stroke, where blood flow to the brain is disrupted.
20. SOB – Shortness of Breath
    Difficulty breathing or feeling breathless.
21. ADL – Activities of Daily Living
    Basic self-care activities like bathing, dressing, eating, and mobility.
22. BKA – Below Knee Amputation
    An amputation that removes the leg below the knee.
23. TKA – Total Knee Arthroplasty
    A surgical procedure in which the knee joint is replaced.
24. GCS – Glasgow Coma Scale
    A scale used to assess a person’s level of consciousness following a brain injury.
25. RBC – Red Blood Cells
    Cells in the blood responsible for carrying oxygen throughout the body.
26. WBC – White Blood Cells
    Cells in the immune system that fight infection.
27. PR – Per Rectum
    Refers to a medication or procedure that is administered or performed via the rectum.
28. NPO – Nil Per Os (nothing by mouth)
    A medical instruction to withhold food and fluids from a patient.
29. PA – Pulmonary Artery
    The artery carrying deoxygenated blood from the right side of the heart to the lungs.
30. BMR – Basal Metabolic Rate
    The rate at which the body uses energy while at rest to maintain vital functions like breathing.
31. PPI – Proton Pump Inhibitor
    A type of medication used to reduce stomach acid production.
32. NSAID – Non-Steroidal Anti-Inflammatory Drug
    A class of drugs used to reduce inflammation, pain, and fever.
33. CXR – Chest X-ray
    A type of X-ray imaging used to look at the organs and structures in the chest.
34. SC – Subcutaneous
    A route of drug administration where the medication is injected into the tissue just under the skin.
35. LMP – Last Menstrual Period
    The date of the last menstrual period, used for calculating pregnancy timelines.
36. R/O – Rule Out
    A term used to indicate that a certain diagnosis is being considered but must be excluded.
37. TDS – Ter Die Sumendum (to be taken three times a day)
    A prescription for taking a medication three times a day.
38. QDS – Quater Die Sumendum (four times a day)
    A prescription for taking a medication four times a day.
39. OD – Oculus Dexter (right eye)
    Often used in ophthalmology to refer to the right eye.
40. OS – Oculus Sinister (left eye)
    Used in ophthalmology to refer to the left eye.

 

How to deal with abbreviations in your medical records

If you’re reading through your records and come across medical abbreviations that you don’t understand, it’s perfectly okay to ask your doctor for clarification. GP practices and hospitals are now providing patients with access to their medical records online through patient portals, making it easier to spot unfamiliar terms.

If you’re unsure about something in your record, consider the following:

• Ask your doctor or nurse: They can explain abbreviations and their relevance to your health.
• Look up terms online: The NHS website offers extensive explanations of medical terms and conditions.
• Request your records in simpler language: Some patients find it helpful to request summaries or copies of their medical notes written in layman’s terms.

 

Ask questions

As a patient, it’s always a good idea to actively engage with your GP or healthcare provider if you’re unsure about any terms in your medical records. Understanding the information in your medical documents is important, so if you are unsure about any terms used in your records, contact your Primary Care 24 GP practice with any questions you have.