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When Medical Abbreviations Leave You Annoyed AF
A doctor deciphers the jargon so you can navigate the age of open notes
On April 5th, 2021 a federal law titled the 21st Century Cures Act took effect mandating that clinical notes be made available to patients free of charge. While many medical facilities were already in the practice of releasing laboratory and imaging results to patients electronically, these results were often reviewed by providers prior to becoming available to patients. Now results must be released immediately.
Not surprisingly, I have already encountered a number of displeased patients who would have preferred hearing about, for example, a new lung nodule found on a CT scan, from their doctor rather than seeing it pop up on their electronic patient portal and being left to wonder what it might mean. Electronic records are a powerful tool, but they can be puzzling and even frightening without guidance from a professional to put the information into context.
The Cures Act also resulted in the immediate availability of clinician notes to patients. While this change affords the opportunity for patients and their loved ones to better understand their diagnoses and plan of care, it also carries the potential to create confusion and misunderstanding — particularly for those who don’t speak medicalese.
In an attempt to provide some degree of clarity, I’ve compiled a list of abbreviations and medical terms that one might encounter in a provider note. This is far from a comprehensive list but focuses on the most common medical abbreviations. It’s geared toward documentation found in the inpatient (i.e. hospital-based) as opposed to the outpatient (clinic-based) setting.
I tried to group items by organ system when possible. If you think of an abbreviation missing from this list that you believe belongs, please write a comment. Bonus points if you can guess what the handwriting says in the title image. Also, this is not a static list, and I plan to update it as I become aware of more items that should be added. Without further ado:
