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Medical Jargon Deciphered – Know What Doctors Are Really Saying

SyberScribe AUTHOR: SyberScribe, July 1st, 2019

If you’re thinking about pursuing a career in medical transcription or you’ve been assigned transcription work by your healthcare employer, it’s important you fully understand the jargon and abbreviations used by the medical profession. This article lists some of the most common of these, along with some tips on when and when not to use them in transcription.

When and when not to use abbreviations

The golden rule with abbreviations is that you should only use them if they are widely known and will not lead to potentially dangerous misunderstandings or confusion. That means they should not be used when referring to the names of medications or operating procedures or in any patient diagnoses. They should also not be used if they could possibly have more than one meaning, and should only be used if the full name has been stated beforehand in the transcription.

Apart from these instances, abbreviations can be used if the term is one that is repeated regularly in the transcript, if it is widely known by most people in the medical industry, or if its full title involves three or more words. If the term is to be used frequently, it should be stated in full the first time it appears, accompanied by the abbreviation in brackets and then used in abbreviated form throughout the remainder of the transcript.

Popular jargon

A | B | C | D | H | I | L | M | N | P | R | S | T | U

A

Acute paronychia An infected fingernail.
Aneurysm A sac that’s formed as a result of an enlarged and weakened wall in the arteries, veins or heart.
Antibiotic A substance that kills bacteria.
Antidote A remedy for poison.
Antiseptic A substance that kills germs and therefore prevents infection or decay.
Anuric Unable to produce urine.
Asymptomatic Having no symptoms.

B

Bandemia An excess of band cells (white blood cells) released into the blood via a bone marrow.
Benign Harmless and not cancerous.
Bibasilar At the bases of both lungs.

C

CAT scan An x-ray image of an organ, particularly the brain.
Capillary hemangiomas Strawberry birthmarks.
Carcinogenic Produces cancer.
Coagulate To become thick or to clot, as in a fluid, especially blood.
Comatose Being unconscious or in a state of coma.
Concussion An injury to the brain as a result of a violent blow or impact.
Convalescence A slow recovery or a period of recovery.

D

Diagnosis A decision or opinion that’s based on a patient examination.

H

Haemorrhage To bleed due to an escape of blood from a ruptured blood vessel.
Hematoma A collection of clotted blood outside a blood vessel.

I

Idiopathic A symptom or condition for which the cause is obscure or unknown.
Incision A surgical cut made in the skin or flesh.

L

Lacerated To tear or make deep cuts in the flesh or skin.
Lesion An injury.
Low hemoglobin level Suggests a loss of blood, cancer or problems with the kidneys.

M

Melanoma A malignant tumour, usually associated with skin cancer.
Metabolic syndrome A group of risk factors that increases your risk for heart disease, stroke and diabetes.
Migraine A recurrent intense headache.
Modalities of therapy Treatments.
MRI scan A scan of the body in order to view an organ or body part.

N

Negative Normal test results, which means good news.

P

Plasma The colourless fluid part of the blood.
Positive Abnormal test results, which means bad news.
Pre-diabetes If a person who’s fasted or not eaten for 8 hours has a blood sugar level between 100-126, it means they have pre-diabetes, which is an increased risk of getting diabetes in the future.
Prognosis An opinion of the likely course of a disease and the odds of recovery.

R

Remission The disappearance of the symptoms of a disease.

S

Sonogram A visual image produced from sound waves to see what’s going on inside the body, such as an ultrasound examination.
Spontaneous involution A medical condition that disappears on its own.
Suture A stitch or stitches, where two edges of a wound or incision are joined together with a thread.

T

Therapy The treatment of a disease.
Toxic Poisonous.

U

Ulcer An open sore on an internal or external surface of the body, such as in the stomach lining.

Essential abbreviations to know

The following abbreviations are essential to know when transcribing medical information.

A|B|C|D|E|F|G|H|I|J|K|L|M|N|O|P|Q|R|S|T|U|V|W|X

A

AAA (pronounced triple-a) Abdominal aortic aneurysm
a.c. Before meals
Accels Accelerations
ACL Anterior cruciate ligament
Ad lib At liberty, as desired
Admit Admission
A-fib Atrial fibrillation
A/G ratio Albumin to globulin ratio
AKA Above the knee amputation
Alk phos Alkaline phosphatase
Amox Amoxicillin
Angio Angiography
Appy Appendectomy

B

Bicarb Bicarbonate
b.i.d. Twice daily
Bili / bilis Bilirubin / bilirubins
BKA Below the knee amputation
BMI Body mass index
BMP Basic metabolic panel
BP Blood pressure
Brady Bradycardia
BSO Bilateral salpingo-oophorectomy

C

CABG (pronounced cabbage) Coronary artery bypass grafting
C&S Culture and sensitivity, performed to detect infection
Cap Capsule
Cath Catheter / catheterisation
Cath’d Catheterised
CAT scan Computed axial tomography scan
CBC Complete blood count
C/C Chief complaint
CC Cubic centimetres
C. diff Clostridium difficile
Chemo Chemotherapy
Chem panel Chemistry panel
Circ Circumflex
C/O Complaint of
Coags Coagulation studies
Consult Consultation
COPD Chronic obstructive pulmonary disease
Crit Haematocrit
Cryo’d Had cryotherapy
C-section Caesarean section
C-spine Cervical spine
CVA Cerebrovascular accident
Cysto Cystoscopy

D

D&C Dilatation and curettage
Dc Discontinue / discharge
Dc’d Discontinued / discharged
DDX Differential diagnosis
Decels Decelerations
Decubiti Decubitus ulcer / decubitus ulcers
Desats Desaturations
Detox Detoxification
Dex Dexamethasone
Dig Digoxin / digitalis
Dip /dexi / d-stix Dipstix / dextrostix
DM Diabetes mellitus
DNR Do not resuscitate
Doc Doctor
DOE Dyspnea on exertion
DTR Deep tendon reflexes
DVT Deep venous thrombosis /deep vein thrombosis

E

E. coli Escherichia coli
Endo Endoscopy
Eos Eosinophils
Epi Epinephrine
Epis Epithelial cells
ETOH Alcohol
Exam Examination
Ex lap Exploratory laparotomy

F

Feeds Feedings
Fem-pop Femoropopliteal
Fem-pop bypass Femoropopliteal bypass
Flex sig Flexible sigmoidoscopy
Fluoro Fluoroscopy
FX Fracture

G

Gastroc Gastrocnemius
Gent Gentamicin
GOMER Get out of my emergency room (slang)
GTT Glucose tolerance test / drops

H

HA Headache
H&H Haemoglobin and haematocrit
H&P History and physical examination
H. flu Haemophilus influenzae
Heme/onc Haematology/oncology
Hep A Hepatitis A
Hep B Hepatitis B
Hep C Hepatitis C
High res High resolution
H/O History of
H. pylori Helicobacter pylori
h.s. At bedtime
HTN Hypertension

I

I&D Incision and drainage / irrigation and debridement
I’s & O’s / I& O’s Inputs and outputs
IM Intramuscular
IMP Impression
In-vitro In the laboratory
In-vivo In the body
IU International units
IVDA Intravenous drug abuse

J

JT Joint

K

K Potassium
KCL Potassium chloride

L

Lab Laboratory
Labs Laboratory studies
Lac Laceration
Lami Laminectomy
Lap Laparotomy
Lap chole Laparoscopic cholecystectomy
LBP Low back pain
LDL Low-density lipoprotein
LFTs Liver function tests
LLQ Left lower quadrant
L-spine Lumbar spine
LUQ Left upper quadrant
Lymphs / lymphos Lymphocytes
Lytes Electrolytes

M

Maxed out Maximised
MCL Medial collateral ligament
Med onc Medical oncology
Meds Medications
Met Metastasis
Mets Metastases
mg Milligrams
Micro Microscopic analysis
Mics (pronounced mikes) Micrograms
mL Millilitres
MRI scan Magnetic resonance imaging scan
Mucusy Mucus-like
MVI Multivitamin
MVP Mitral valve prolapse

N

Na Sodium
Neb / nebs Nebuliser / nebulisers
Neuro Neurologic / neurological / neurology / neurosurgical
Nitro Nitroglycerin
NPO Nil per os / nothing by mouth
NSAID (pronounced en-sed) Non-steroidal anti-inflammatory drug
N/V Nausea or vomiting

O

O&P Ova and parasites
O.D. Right eye
OD’d Overdosed
ORIF Open reduction and internal fixation
O.S. Left eye
Osteo Osteoporosis
O.U. Both eyes
Ox Oximetry
O2 sat Oxygen saturation

P

P  Pulse
Pacer  Pacemaker
Path  Pathology
PCL  Posterior cruciate ligament
Ped / peds  Pediatric / pediatrics
Pen  Penicillin
Pen-vee k  Penicillin V potassium
PERRLA  Pupils equal
Phaco  Phacoemulsification
Plastics  Plastic surgery
PLT  Platelets
PMI  Point of maximum impulse
PO  Per os / by mouth
Polys  Polymorphonuclear cells
Postop  Postoperative
Preemie  Premature infant
Preop  Preoperative
Prepped  Prepared
p.r.n.  As needed
Pulse ox  Pulse oximetry
Pussy  Pus-like
Pyelo  Pyelogram

Q

Q&Q Quinine and quinidine
qAM Each morning
q.d. Each day
q.h.s. At each bedtime
q.i.d. Four times daily
q.o.d. Every other day
qPM Each evening
q2h Every 2 hours
q3h Every 3 hours
Quads Quadriceps

R

Rad onc Radiation oncology
REB Rebound
Regurg Regurgitation
Rehab Rehabilitation
Rehabbing Rehabilitating
Retic count Reticulocyte count
Reticking Producing reticulocytes
RLQ Right lower quadrant
R/O Rule out
ROS Review of systems
RUQ Right upper quadrant

S

Sat Saturation / oxygen saturation
Sats Saturations / oxygen saturations
Satting Saturating
Schizo Schizophrenia
Script Prescription
Sed rate Sedimentation rate
Segs Segmental cells
SOB Shortness of breath
Sono Sonogram
Sono’d Had a sonogram
S/P Status post
SQ Subcutaneous
Staph Staphylococcus
Staph epi Staphylococcus epidermidis
Strep Streptococcus

T

T Temperature
Tab Tablet
TAH Total abdominal hysterectomy
T&A Tonsillectomy and adenoidectomy
Terb Terbutaline
Terb drip Terbutaline drip
Theo Theophylline
THR Total hip replacement
Tib-fib Tibia-fibula / tibiofibular
t.i.d. Three times daily
TKR Total knee replacement
T-max Temperature maximum
Tox Toxicology
Toxo Toxoplasmosis
Trach Tracheostomy
Trached Tracheostomy placed
Trich Trichomonas
T-spine Thoracic spine

U

UA Urinalysis
URI Upper respiratory infection
Urine osmo Urine osmolality
ut dict As directed
UTI Urinary tract infection

V

Vag-hyst Vaginal hysterectomy
Vanc Vancomycin
VBAC (pronounced vee-back) Vaginal birth after caesarean section
V-fib Ventricular fibrillation
Vitals Vital signs
VSS Vital signs are stable
V-tach Ventricular tachycardia

W

WBC count White blood cell count
WT Weight

X

XRT Radiation oncology

Using the convenience of medical abbreviations with care

While knowing and understanding medical jargon and abbreviations goes a long way towards becoming a competent medical transcriber, transcribing this information at a consistent and high level will take months of practice to master. While you improve on these skills, SyberScribe can assist in providing high quality medical transcription with a reliable turnaround. Contact us today to find out more.