Deciphering Patient Records
From OpenHealthRecord
If you get a copy of your patient records from your doctor or GP then you will will find that some of the older details will have been written by hand. Doctors appear to use a lot of shorthand which I hope is a fairly universal code.
The purpose of this page is to create a list of symbols, abbreviations and notations and provide, where known, an interpretation of these.
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Useful Resources
- Pharma-Lexicon
- Stanford - Approved Abbreviations
- Stanford - Dangerous Unapproved Abbreviations
- Consumer Health Vocabulary - A very useful resource from BWH
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Symbols, Abbreviations and Notation
| Country | Notation | Meaning | |
|---|---|---|---|
| UK | A, V C, column on an FP7 (LLoyd George) Envelope | "This column has been provided for doctors to enter either A V or C at their discretion." A = Attendance, V=Visit, C=National Insurance Certificate issued. | |
| # | Fracture or broken bone. | ||
| ! | Usually used it indicate an abnormal result from a lab test | ||
| + | Severe (eg Pain+ means severe pain). | ||
| ++ | Very severe (eg Pain++ means very severe pain). | ||
| BD | Twice a day (usually in the context of a prescription) | ||
| D.N.A. | Did not attend (appointment) | ||
| IMI | Intra-muscular injection (also written as IM) | ||
| IVI | Intra-venous injection (also written as IV) | ||
| L in a circle | Left, as in left foot, left arm, left eye. | ||
| O | Oral | ||
| OD | Once a day (usually in the context of a prescription, also written as QD) | ||
| PFA | Patient functional assessment | ||
| PGA | Physician's global assessment | ||
| PR | Rectal (usually in the context of administering a medication) | ||
| Pt | Patient | ||
| PV | Vaginal (usually in the context of administering a medication) | ||
| QD | Once a day (usually in the context of a prescription) | ||
| QID | Four times a day (usually in the context of a prescription) | ||
| R in a circle | Right, as in right foot, right arm, right eye. | ||
| Rx | Prescription | ||
| SC | Subcutaneous (just under the skin) | ||
| SL | Sublingual (under the tongue) | ||
| T | Tablet | ||
| TCI | To come in. Normally means to be admitted to a hospital, not "to come in" to the doctor's surgery, even though written by the doctor. | ||
| TDS | Three times a day (usually in the context of a prescription, usually written as tid) |
