Medical Abbreviations for Attorneys: A Practical Medical Record Glossary

Common Medical Abbreviations Attorneys Encounter

Symptoms and Presenting Complaints

Abbreviation	Common meaning	Review point
Pt	Patient	“PT” may mean physical therapy or prothrombin time.
c/o	Complains of	Usually introduces a reported symptom, not a diagnosis.
CP	Chest pain	May mean cerebral palsy in another context.
SOB	Shortness of breath	Check onset, severity, oxygen level, and related symptoms.
HA	Headache	Does not identify the type or cause.
N/V	Nausea and vomiting	Confirm whether both symptoms were present.
LOC	Loss of consciousness or level of consciousness	Use the surrounding note to determine meaning.
AMS	Altered mental status	A descriptive finding with many possible causes.
DOE	Dyspnea on exertion	Shortness of breath during activity.
TTP	Tenderness to palpation	Identify the body area.
ROM	Range of motion	May be full, limited, active, passive, or painful.
NAD	No acute distress	Does not mean no injury, illness, or pain.

History and Examination

Abbreviation	Common meaning	Review point
Hx	History	May refer to the full history or one prior condition.
HPI	History of present illness	Often describes symptom onset and progression.
PMH	Past medical history	Relevant to prior conditions and alternative causes.
PSH	Past surgical history	Confirm details in operative reports.
FH/FHx	Family history	May identify hereditary risk factors.
SH/SocHx	Social history	May include smoking, alcohol, work, and activity.
ROS	Review of systems	May be limited by templates or patient reporting.
PE	Physical examination	May also mean pulmonary embolism.
A&O x3	Alert and oriented to person, place, and time	Some records use x4 to include situation.
NVI	Neurovascularly intact	Often appears in trauma and orthopedic records.
WNL	Within normal limits	Check what was examined.

Assessment and Diagnostic Status

Abbreviation	Common meaning	Review point
Dx	Diagnosis	May be provisional, working, discharge, or final.
Ddx	Differential diagnosis	Lists possibilities, not confirmed conditions.
r/o	Rule out	Means a condition was considered or evaluated.
s/p	Status post	Refers to a prior procedure or event.
NED	No evidence of disease	Limited to available evidence at that time.
Acute	Recent onset or short clinical course	Does not necessarily mean severe.
Chronic	Persistent or long-standing	Does not establish onset or continuous symptoms.

Laboratory and Imaging

Abbreviation	Common meaning	Review point
CBC	Complete blood count	Review the component results.
BMP	Basic metabolic panel	Commonly includes electrolytes, glucose, and kidney measures.
CMP	Comprehensive metabolic panel	Includes additional measurements, often liver-related tests.
UA	Urinalysis	Check whether microscopy or culture was performed.
PT/INR	Prothrombin time and international normalized ratio	“PT” may also mean physical therapy.
CXR	Chest X-ray	Locate the radiology report.
CT	Computed tomography	Confirm the body area, contrast, and impression.
MRI	Magnetic resonance imaging	Review findings, comparisons, and limitations.
EKG/ECG	Electrocardiogram	Identifies the test, not what it excluded.
Trop	Troponin	Timing and serial results may matter.
US/U/S	Ultrasound	Confirm the body area and interpretation.

Treatment, Medication, and Follow-Up

Abbreviation	Common meaning	Review point
Tx	Treatment	Identify the intervention.
Rx	Prescription or treatment	May refer to medication or a broader plan.
PO	By mouth	Route of administration.
IV	Intravenous	Given into a vein.
IM	Intramuscular	Given into a muscle.
PRN	As needed	Check the condition and maximum frequency.
BID	Twice daily	Confirm actual administration.
TID	Three times daily	Review dates and missed doses.
QID	Four times daily	Confirm the intended interval.
NPO	Nothing by mouth	Often used before a procedure.
WBAT	Weight bearing as tolerated	Common after orthopedic injury or surgery.
NWB	Non-weight-bearing	Confirm the extremity and duration.
PT/OT	Physical therapy and occupational therapy	Review evaluations, attendance, and progress.
D/C or DC	Discharge or discontinue	Context determines which meaning applies.
F/U	Follow-up	Confirm the provider, purpose, and timing.
RTC	Return to clinic	Check whether the visit occurred.
AMA	Against medical advice	Review capacity, risks, and reasons for leaving.
SNF	Skilled nursing facility	Confirm the facility, dates, and services.
HHA	Home health aide or agency	Meaning depends on context.

How to Read a Medical Note in Context

Consider this emergency-department entry:

Pt c/o CP x2d. r/o MI. EKG nl; Trop negative. DC’d w/ F/U rec.

A basic translation is:

The patient reported chest pain for two days. The team considered or evaluated the patient for myocardial infarction. The electrocardiogram was described as normal, the recorded troponin result was negative, and the patient was discharged with a follow-up recommendation.

That translation does not answer:

What was the character and severity of the pain?
When did symptoms begin relative to testing?
Were serial troponin tests obtained?
What was the final diagnosis?
What follow-up was recommended?
Did the patient return with continuing symptoms?

“R/o MI” does not mean a myocardial infarction was diagnosed or that every cardiac condition was excluded. Review the history, examination, orders, results, medical decision-making, and discharge instructions.

Why Context Matters

Abbreviation	Possible meanings
CP	Chest pain or cerebral palsy
PE	Physical examination or pulmonary embolism
PT	Physical therapy or prothrombin time
MS	Multiple sclerosis or mental status
BS	Blood sugar or bowel sounds
DC	Discharge or discontinue
LOC	Loss of consciousness or level of consciousness

Check the document type, specialty, heading, capitalization, and surrounding entries before selecting a definition.

Medical Terms That Are Not Legal Conclusions

Impression: The clinician’s assessment at that point. It may change after testing or follow-up.

Diagnosis: May be provisional, suspected, historical, billing-related, discharge, or final.

Differential diagnosis: A list of possible explanations, not confirmed conditions.

History of: Usually refers to a prior condition or event, not necessarily an active problem.

Consistent with: Means a finding fits a condition but may not exclude others.

Suggestive of: Raises a possibility but is not necessarily confirmation.

Stable: Usually means no significant worsening during the period described. It does not mean normal or recovered.

Unremarkable: Means no notable abnormality was identified in the area documented. It does not mean no medical condition existed.

Noncompliant or nonadherent: May not explain whether instructions were understood, affordable, practical, or tolerated.

Prognosis: An assessment of the expected course that may change with new information.

Etiology: The known, suspected, multifactorial, or unknown cause of a condition.

A chart phrase does not establish negligence or causation. Read more about the standard of care in medical malpractice cases.

Glossary vs. Chronology vs. Medical Record Review

Task	Primary purpose
Terminology glossary	Translates routine words and abbreviations
Record organization	Sorts, labels, indexes, and deduplicates files
Data extraction	Pulls dates, diagnoses, medications, procedures, and values
Medical chronology	Arranges events by date and source
Medical summary	Condenses important information
Medical record review	Evaluates clinical significance
Expert opinion	Provides a qualified opinion on a defined issue

A medical chronology helps counsel determine what happened, when, and where the source can be found. Expert Institute’s Medical Chronologies organize events into a timeline.

A medical record review for attorneys evaluates clinical significance for defined questions, including causation, prior conditions, prognosis, conflicting findings, and missing documentation.

When a Glossary Is Not Enough

Consider clinical review when:

An abbreviation has several plausible meanings.
The note is incomplete, templated, or contradictory.
Providers describe the same event differently.
A diagnosis appears in one section but not the final assessment.
Laboratory or imaging findings must be interpreted over time.
The issue involves causation, prognosis, prior conditions, or medical necessity.
A party relies on an isolated phrase.
Counsel needs an opinion rather than a factual translation.

Technology can assist with sorting, extraction, and preliminary timelines. It should not replace clinical judgment when a disputed issue depends on medical significance. See AI medical record review versus physician-led review.

Attorney Checklist for Medical Shorthand

Read the complete note.
Identify the author, specialty, and care setting.
Determine whether the entry is reported, observed, tested, or diagnosed.
Check the assessment and plan.
Locate the original test or imaging report.
Compare earlier and later records.
Distinguish a differential diagnosis from a final diagnosis.
Do not treat “rule out” as confirmation.
Preserve the source page and date.
Flag ambiguous or case-critical entries for clinical review.