Basic rules for acronyms
- 1 Acronyms at the beginning of a sentence
- 2 Common abbreviations
- 3 Abbreviating contractions
- 4 Abbreviating diagnoses and titles
- 5 Abbreviations and acronyms with multiple meanings
- 6 Abbreviated terms used as slang terms
- 7 Abbreviations in units of measure
- 8 Abbreviating terms dictated in full
- 9 Abbreviations and punctuation
- 10 Academic abbreviations
- 11 First-time reference of an abbreviation or acronym
There is no nationally recognized list of approved abbreviations for use in medical reports. The JCAHO requires accredited facilities to have uniform data definitions.
Never guess
Many abbreviations and acronyms have multiple meanings. If it is unclear which expanded form is referenced, use the abbreviation or acronym without expanding and leave a discrepancy flag for the dictator; alternatively, follow procedures as outlined for the account and/or your company.
Productivity
The decision to use an abbreviation should be made on the basis of communication and usage, not financial considerations. Abbreviations, acronyms and brief forms should not be expanded to increase billable units.
Clarify the abbreviation
Be consistent within the same material: do not abbreviate a term in some sentences and spell it out in other sentences. Moreover, having selected one form of an abbreviation (say, c. o. d.), do not use a different style (COD) elsewhere in the same material.
When using an abbreviation that is not commonly accepted in medical terminology or may not be clear, spell out the full term, followed by the with the abbreviation in parentheses, when it is first used.
Commonly used abbreviations and acronyms that have become part of the accepted nomenclature, such as CT and MRI, should not be spelled out.
The patient had symptoms consistent with a cerebrovascular accident (CVA). Diagnostic studies on Tuesday confirmed the diagnosis of CVA.
The patient has a history of myocardial infarction (MI) but has no evidence of MI now for 10 years.
Commonly accepted abbreviations
Some abbreviations are always acceptable: those that precede or follow personal names (such as Mr., Ms., Mrs., Jr., Sr., Esq., Ph.D., and St.); those that are part of an organization's legal name (such as Co., Inc., Ltd.); those used in expressions of time (such as am., p.m., EDT); and a few miscellaneous expressions (such as A.D. and B.C.).
Days, months, geography
Days of the week, names of the months and geographic names should be abbreviated only on business forms, in expedient documents, and in tables, lists, and narrow columns of text where space is tight.
Some geographic locations use the abbreviation for Saint (St.) as part of the location name. In those cases, the word is never spelled out.
St. George, Utah
St. Croix
Short words
When an abbreviation is only one or two keystrokes shorter than the full word (for example, Pt. for Part), do not bother to abbreviate except to achieve consistency in a context where similar terms are being abbreviated.
Don't follow an acronym with a word that is included in the acronym
When using an acronym, do not follow it with a word that is part of the acronym.
WBC count was 9200.
Expand the acronym and the word count is repeated; i.e.,
White blood cell count count was 9200.
Correct: WBC was 9200.
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