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Abbreviations

Cindy Posted Mon 03rd of December, 2018 15:30:18 PM
I have a physician who uses a scribe and the entire medical records are pretty much abbreviated. Many times I have no idea what the abbreviation stands for. Is there a list of acceptable medical terminology abbreviations? I have been reviewing medical records for over 30 years, and this is a first for me. My classes in Medicare advised against using medical abbreviations especially in diagnosis. Are there any rules against this for documentation? Thank you
SuperCoder Answered Tue 04th of December, 2018 06:28:00 AM

Hi,

Thanks for your questions.

The medical record documentation should provide the importance of complete, timely, and accurate health information.

Please find below list of commonly used abrreviation for physical exam which are accepted.

Condition Short Form
No acute distress NAD
Alert, awake & oriented times 4to name, place, time & purpose  AAOX4
Well developed, well nourished WDWN
African american male AAM
African american female AAF
White male WM
White female WF
   
Bilateral tympanic membrane intact and reactive to light b/l TM intact & reactive to light
Mucuos membrane moist MMM
   
Clear to auscultation bilaterally CTAB
No rale/rhonchi/wheezes Ø r/r/w
No egophany Ø egophany
No tactile  fremitus Ø tactile fremitus
Normal percussion nl percussion
   
No bright red blood per rectum, Melena,Masses Ø BRBPR, Melena, Masses
Obese Obese
No pulsatile masses Ø pulsatile masses
Normal bowel sound normal in all four quadrants + BS nl x 4
No high pitched or tinkling sounds Ø high pitched or tinkling sounds
Resonant to percussion Resonant to percussion
Soft Soft
Non-distended/non-tender ND/NT
No rebound or guarding Ørebound/guarding
No costovertebral angle tenderness Ø CVAtenderness
No hepatosplenomegaly Ø HSM
   
Male  
Normal sphincter tone nl sphincter tone
No external or internal hemorrhoids Ø ext/int hemorrhoids
No prostate tenderness, Penile Discharge,Inguinal Hernia Ø prostate tenderness, Penile Discharge,Inguinal Hernia
Bilateral testicles normal in consistency without hydrocele or varicocele b/l testicles nl in consistency s hydrocele or varicocele
No hypospadias or epispadias Øhypospadias or epispadias
Female  
Vaginal mucosa of normal consistency without atrophy or discharge Vaginal mucosa nl consistency s atrophy or discharge
Cervical  os without discharge Cervical  os s discharge
No cervical motion tenderness, Vaginal Bleeding, Discharge,Masses Ø CMT, VB, Discharge, Masses
   
Regular rate and rhythm  RRR
S1 and S2 are normal S1S2nl
No murmur/rubs/or gallops Ø m/r/g
Point of maximal intensity non displaced and non sustained PMI non displaced/non sustained
No Hepatojugular Reflux ØHJR
Capillary refill less than 2 seconds CR <2 sec
   
Normal range of motion nl ROM
No joint swelling or erythema strong>Ø joint swelling or erythema
   
Intact Intact
No rashes Ø rashes
No lesions Ø lesions
No errythema Ø errythema
   
Cranial nerve II through XII intact CN II-XII intact
No focal deficity Ø focal deficit
   
Normal effect nl effect
No hallucinations Ø hallucinations
Normal speech nl speech
No dysarthria Ødysarthria
   
No lymphadenopathy Ø LAD
   
Extraocular muscles intact EOMI
Pupils equal,round & reactive to light & accommodation bilaterally PERRLA
Bilateral sclera anicteric b/l sclera anicteric
No conjunctival injection Ø conjunctival injection
   
   
Normocephalic atraumatic NCAT
Chest pain CP
Non-distended/non-tender ND/NT
Supple  Supple 
No julular venous distention ØJVD
No lymphadenopathy ØLAD
No carotid bruit Ø carotid bruit
No thyromegaly Ø thyromegaly
   
No rashes Ø rashes

 Please feel free to ask if you have any questions.

Thanks.

Cindy Posted Tue 04th of December, 2018 06:54:32 AM
He is not only abbreviating the physical exam, actually all of it is abbreviated, the HPI, the diagnosis. He was looking for a "general" list of accepted abbreviations for medical records, HPI, assessment, treatment and diagnosis. Is there a list and are their regulations on abbreviations.thank you
SuperCoder Answered Wed 05th of December, 2018 07:49:39 AM

Hi,

The above list we provided are the most commonly used medical abbreviation in medical coding. If the abbreviation used are not standard, then you have to discuss with the physician and scirbe to use only the standard abbreviation. 

Hope this helps.

Thanks.

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