Medical chart abbreviations

Whose lists these are

The lists behind these pages are Charleston Area Medical Center’s abbreviations approved for medical records; the North Carolina College of Emergency Physicians’ approved list for EMS, revised in 2023; the Central California EMS Agency’s list, which sets out the abbreviations that may be used in documenting patient care in its system; California Correctional Health Care Services’ clinical list of 2022; and Duke Health’s list for patients reading their notes in MyChart. Duke’s list sometimes adds a plain explanation: DOE, it says, means shortness of breath that occurs on exertion. MedlinePlus, the National Library of Medicine’s health site, lists a few of the same letters.

Where the lists disagree

The abbreviations ending in x show how the lists differ:

The same letters are glossed in different words, too. ETOH is “alcohol” at Charleston and CCHCS, “ethanol or alcohol” for NCCEP and “ethyl alcohol” in Central California, and NIST’s Chemistry WebBook lists EtOH among ethanol’s other names. Charleston ends PERRLA with “accommodate”, and shorter forms are on other lists: PERRL in Central California, PEARL in North Carolina, PERL at CCHCS. A neurology chapter in Clinical Methods (1990) calls PERRLA “a convenient but incomplete description”, since it leaves out the size and shape of each pupil. At Charleston, DOE can also mean date of exam.

Look-alikes

ASA is aspirin, or acetylsalicylic acid, on the hospital and EMS lists, and PubChem gives ASA among aspirin’s synonyms. It is also the American Society of Anesthesiologists, whose physical status classes run from ASA I, a normal healthy patient, to ASA VI, with an E added for emergency surgery. ROSC has two definitions in use. NEMSIS’s data dictionary for EMS records counts any restoration of circulation lasting more than about 30 seconds as “any ROSC”; a 2020 study gives the Utstein definition of sustained ROSC, when chest compressions have not been needed for 20 consecutive minutes. SOB, short of breath, is the neighbouring entry to DOE; Clinical Methods defines dyspnea as the sensation of difficult or uncomfortable breathing. PCN sits near NKA (no known allergies) and NKDA (no known drug allergies) on Charleston’s list. The CDC reports that about 10% of US patients say they have had an allergic reaction to a penicillin-class antibiotic, and that fewer than 1% are truly allergic. For ADL, StatPearls lists basic tasks such as eating, dressing, bathing and toileting, sets them apart from instrumental ADLs such as managing finances, and credits the term to Sidney Katz in 1950.

What ISMP and the Joint Commission flag

The Institute for Safe Medication Practices (ISMP) recommends in its list of error-prone abbreviations that drug names not be abbreviated, and gives APAP for acetaminophen as an example of one involved in medication errors. That covers ASA and PCN, though neither is one of the list’s named examples. The Joint Commission created its “Do Not Use” list in 2004; it names forms such as QD (daily) and QOD (every other day), which are mistaken for each other, and none of the eight abbreviations here. Those forms are on the prescription abbreviations pages, with Rx.