Brief Forms and Medical Slang
1. Brief forms are shortened forms of legitimate words that can be documented in a reputable dictionary or have come into acceptance through usage. A slang term is either not listed in a dictionary or is designated as slang.
2. Medical slang should be avoided in medical documents for several reasons. A slang term may be obscure and might not clearly or accurately convey the intended meaning. Additionally, a slang term may be open to varied interpretations by different readers of the record, particularly obvious when a health record is subpoenaed by legal process.
3. Slang terms used disparagingly to refer to patients should be avoided. Physicians do not intend for offensive or offcolor remarks to be entered into a patient's health record.
4. Brief forms can be easily confused with medical slang. Physicians commonly use medical slang when discussing a patient's condition, but that does not mean the same slang term is acceptable in the medical report transcript.
5. Following are some terms that are currently deemed acceptable, unacceptable, or equivocal. A good rule to remember is, "When in doubt, write it out."
Acceptable Brief Forms
ab, AB abortion
bands band neutrophils
Pap smear Papanicolaou smear
polys polymorphonuclear leukocytes
pro time prothrombin time
sed rate sedimentation rate
segs segmented neutrophils
Unacceptable Medical Slang
cath, cath'd catheter, catheterized
coags coagulation studies
DC, DC'd discharge(d), discontinue(d)
dig ("dij") digitalis
fib fibula, fibrillation
H. flu H. (Haemophilus) influenzae
H&H hemoglobin and hematocrit
Metz Metzenbaum scissors
romied verb form of ROMI (rule out MI)
tabby therapeutic abortion
V fib ventricular fibrillation
V tach ventricular tachycardia
Equivocal Medical Slang/Abbreviations
BP blood pressure