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Abbreviations and Acronyms

Basic Rules for Abbreviations

Abbreviations, acronyms and slang terms are often used in medical documentation but they frequently create confusion. When transcribing or typing medical documents or medical-legal documents, it's important to make certain that any abbreviations, acronyms or slang terms do not create a potential for misinterpretation. Confirm against information in the record to ensure contextual accuracy and clarity.

In discussions about abbreviations, the most common type of abbreviation is the abbreviation of a word to a shortened form.

Image
cont. for continued
Wed. for Wednesday
Jan. for January
etc.

Where formal style is appropriate, such as medical documentation, follow the rule: when in doubt, spell it out.

Some abbreviations are always acceptable, even in the most formal contexts, such as those that precede or follow personal names (Mr. Ms., Jr., Sr., etc.), that that are part of an organization's legal name (Co., Inc., etc.), expressions of time (a.m., p.m., CST, etc.), and a few miscellaneous expressions (such as A.D. and B.C.).

Days of the week, names of months, and geographic names are abbreviated only in tables, lists and narrow columns of text. In medical documentation, they should be spelled out.

Consult a dictionary or authoritative reference for acceptable forms of abbreviations. As always, follow your employer's guidelines, or account-specific guidelines. 

There are three additional types of abbreviated forms.

  • Initialism: An abbreviation formed from the initial letters of each word or major parts of the term or phrase, then pronounced not as a word by by each letter.
  • Acronym: This is an abbreviation formed by the initial letters of each word in the phrase, or major parts of the term or phrase, or selected letters of a word or phrase that is pronounced as a word.
  • Brief form: An abbreviation that is a shortened form of a single word, rather than the initial letters of a series of words. This can include slang terms that are actually abbreviated forms of longer words, many of which have become accepted in the common venacular of English language.

Initialism

Image
a.m. (ay em)
p.m. (pee em)

Acronym

Image
AIDS = Acquired Immune Deficiency Syndrome)
GERD (pronounced gurd) = GastroEsophgeal? Reflux Disorder
LASER = Light Amplification by Stimulated Emission of Radiation

Note: The word laser was originally written as LASER, then accepted into common usage as a word and dropped to all lower case. 

Brief Form

Image
exam (brief form of examination)
phone (brief form of telephone)

Occasionally, an abbreviation may have two acceptable pronunciations.

Image
URL (uniform resource locator, which refers to a specific address on the WWW): When pronounced you-are-el, it is an initialism; when pronounced earl, it is an acronym.

The use of the articles "a" or "an" before an abbreviation or acronym will depend on whether the abbreviation is an initialism or an acronym.

Abbreviations and acronyms can create confusion, as abbreviations can represent more than one meaning.

Review the Basic rules for acronyms for more information.

General Use

Avoid the use of abbreviations, acronyms and brief forms except for internationally recognized and accepted units of measure, and for widely recognized terms and symbols.

Unless the abbreviation, acronym or brief form is widely recognized and has essentially become a term in its own right, use the expanded form for the first instance in the document, followed by the abbreviated form in parentheses, then use the abbreviated form throughout the remainder of the document.

Image
CT scan (no expansion necessary)
LASIK (no expansion necessary)
AIDS (no expansion necessary)

D: The patient presents with chief complaint of UTI. His mother says the first symptoms of UTI were apparent yesterday.
T: The patient presents with chief complaint of urinary tract infection (UTI). His mother says the first symptoms of UTI were apparent yesterday.

As always, the preferences of the employer, client or account take precedence.


Contributors to this page: admin .
Page last modified on Friday 23 of March, 2012 15:49:46 UTC by admin.
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