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:
CC: SOB.
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?)
About the clever pop-up definitions thing – the first thing that comes to mind is: now I need another level, to answer “Okay, so what the heck is THAT?”
You know, Dave, I had that very thought. Still this is a really cool tool and I’m so glad to be participating here. I’m working to get more medical transcriptionists involved ss well since they work with healthcare documents every day!
This looks like a great project and I will be participating. Also shared it to FB already.
Kathy, is it possible to add a field for contributors to sign their additions?
Sure we can do that if you’d like to have that. It just means you’ll have to upload the form here again. I’ll send that to you so you can do that if you’d like!
If I put in an entry and it is already there is the system going to be able to catch it or do I have to check the glossary first?
You don’t have to go through the entire list. It will mean it shows up twice, but we’re going to go through and pull duplicates as we get more entries!
My favorite entry in the glossary so far is the BRAT diet! :–)
Some folks have been having trouble with the pop up that expands the abbreviations. I know that can be frustrating so I’ve added them to the document here so you don’t have to wait to get that part figured out. Hope that helps!
CC (Chief Complaint): SOB.(Shortness of breath)
HPI (History of present illness): This is a 52-year-old black female with a long history of CAD (coronary artery disease) and COPD (chronic obstructive pulmonary disease) who presents with of several days’ duration. She has had some DOE (dyspnea on exertion) but no chest pain or diaphoresis. She has had an MI (myocardial infarction) in the past with CABG (coronary artery bypass grafting) in 1999 of 4 occluded vessels.
PMH (Past medical history): Her past medical history is significant for GERD (gastroesophageal reflux disease) for which she takes Prevacid daily and TAH (total abdominal hysterectomy) with BSO (bilateral salpingo-oophorectomy) in her late 40’s.
PE (Physical examination): She is A&O x3 (alert and oriented to person, place and time). PERRLA (Pupils equal, round, and reactive to light and accommodation). EOMI (Extraocular movements intact). Nose and throat are clear. Lungs revealed some rales on A&P (auscultation and percussion). No wheezes or rhonchi. HEART: RRR (Regular rate and rhythm). No MRG (murmurs, rubs, or gallops). ABDOMEN: Soft and nontender. No HSM (hepatosplenomegaly). No CVAT (costovertebral angle tenderness). EXTREMITIES: No CCE (clubbing, cyanosis or edema). DTRs (Deep tendon reflexes) are intact.
LAB: CBC (Complete blood count) revealed a normal H&H (hemoglobin and hematocrit). Urine for C&S (culture and sensitivity) was normal. EKG was WNL (within normal limits). CXR (Chest x-ray) revealed atelectasis and infiltrate.
Thanks for expanding the definitions. I wasn’t getting pop ups. I will forward this to my colleagues. Did you put it on LinkedIn, in some of the groups?
Thanks again,
NJ
I did post it through my Twitter account which is connected to my LinkedIn account. Please DO feel free to share it anywhere you think would be valuable!
If you happen to have a big list of abbreviations in Excel, you can contact me and I will import those to save you the time of manually entering every single one. That might make it a bit faster and get more into the system!
This week US News & World Report posted a set of definitions, titled Decoding Doctor-Speak: Translations of Common Medical Terms. Anyone want to add them in to the glossary we started?
Thanks for the tip to @HealthLitMo, Health Literacy Missouri.