Abbreviations and Brief Forms

Brief Forms

are commonplace in medical transcription editing. Some are acceptable and some are not. Brief forms are simply shortened forms of words. Brief forms are to be edited as dictated unless they appear in headings, diagnoses, and operative titles. You should lowercase the brief form unless it is routinely capitalized. An ending period is not used, and the plural of a brief form is accomplished by adding the letter s without an apostrophe. Some of your accounts may prefer the expansion of brief forms on the job, and some brief forms are not acceptable at all.

u.d.

as directed

p.r.n.

as needed

a.c.

before food

p.o.

by mouth

n.p.o.

nothing by mouth

Examples of some brief forms both medical and non-medical:

phone Pap smear exam segs infarct fax temp

State and territory names

should be abbreviated if they are preceded by a city, a state, or a territory name. States should be abbreviated in an address. Names of states, territories, and countries should not be abbreviated if they are used alone

t.i.d.

3 times a day

q.i.d.

4 times a day

Drug Terminology Abbreviations and Punctuation

Drug dosages are often abbreviated and kept "as is," when editing. The following list should not be translated/expanded.

Abbreviation

English Translation

The following illustrate some examples of this rule:

My brother was taken to an operating room in Kansas City, MO, when we visited recently. I am looking forward to seeing the specialist in California.

Dangerous Abbreviations

The Institute for Safe Medication Practices (ISMP) has designated a list of abbreviations that are deemed dangerous to the patient's safety according to how they are edited. This list appears in your BOS 3E pages 206-213. You can also find a PDF copy of the ISMP Dangerous Abbreviations list by visiting the following link: http://www.ismp.org/tools/errorproneabbreviations.pdf.

Examples of abbreviations:

WBC (white blood count) USMC (United States Marine Corps) t.v. (television) TB (tuberculosis)

p.c.

after food

n.r.

do not repeat

gtt.

drops (preferred if you spell out drops)

q.4 h.

every 4 hours (note the space: q.4 h. is used for clarity)

q.h.

every hour

abbreviation

is a shortened form of a word or a phrase that is used in place of the whole. Abbreviations are prevalent in the world of medicine. According to BOS 3, it is generally preferred to write out an abbreviation or acronym in full if it is used in the admission, discharge, preoperative, or postoperative diagnosis; in the consultative conclusion; or in the operative title. Non-disease-entity abbreviations accompanying diagnostic and procedure statements may be used if dictated. (It is preferable to abbreviate units of measure.) When you are unable to translate an abbreviation or shortened form within one of these sections, you would normally flag it for attention.

b.i.d.

twice a day