Guest post by medical transcriptionist Kathy Nicholls, member of the Society for Participatory Medicine. This idea grew out of a discussion on the SPM members listserv. To join, see instructions at bottom.
The world of health care is filled with abbreviations. Sometimes that makes it really hard to understand what’s being said in the medical record. Deciphering all of those abbreviations to get real understanding can be challenging.
We’ve all been there. Request a copy of your medical records, and you find yourself staring at a document that may look something this:
HPI: This is a 52-year-old black female with a long history of CAD and COPD who presents with SOB of several days’ duration. She has had some DOE but no chest pain or diaphoresis. She has had an MI in the past with CABG in 1999 of 4 occluded vessels.
PMH: Her past medical history is significant for GERD for which she takes Prevacid daily and TAH with BSO in her late 40’s.
PE: She is A&O x3. PERRLA. EOMI. Nose and throat are clear. Lungs revealed some rales on A&P. No wheezes or rhonchi. HEART: RRR. No MRG. ABDOMEN: Soft and nontender. No HSM. No CVAT. EXTREMITIES: No CCE. DTRs are intact.
LAB: CBC revealed a normal H&H. Urine for C&S was normal. EKG was WNL. CXR revealed atelectasis and infiltrate.
We’re starting a project to help make that easy. It will create a document of abbreviations and acronyms and their meanings so that patients can use it to better decipher their medical records.
Where You Come In
You’ve run across those abbreviations. How about helping creating that glossary? Here is a form for the SPM Abbreviation List where you can make additions. Once we have collected responses, we will put together a glossary that will help understand how these are used in the healthcare record.
Here’s the glossary as it currently sits. If you want to add an entry, use the form below:
Using The Form
The form has been created with 3 simple entry sections. In the first section, you add the abbreviation or acronym. Section 2 is for the “expansion” of that abbreviation. Section 3 is left for any additional description or explanation that you think might be helpful. Only the first 2 sections are required for an entry.
You can also help by sharing this post with others who might be interested in contributing. Collectively we should be able to come up with something that really provides value for patients as they read their healthcare records.
Kathy’s website is http://mtinnercircle.com/
To participate in the listservs of the Society for Participatory Medicine, join. It’s just $30/year for individuals. Organizational members welcome too, at all levels! See our member list.
Tip: To see what the abbreviations in the example mean, mouse over each one. We’ve hand-coded a pop-up definition into each one. Wouldn’t that be nice to have for all medical web pages?? Perhaps with varying levels of detail? Maybe someday. –e-Patient Dave
(This isn’t working for all users – might depend on your browser. Try right-clicking instead?)