Medical Abbreviation List for Transcriptionists

Medical transcription services have become a practical option for converting voice-recorded dictations from healthcare professionals into text. Doctors often use abbreviations in their dictations to save time, so transcriptionists must be fairly familiar with commonly used medical abbreviations – which is why we created this list.

Even minor mistakes in this abbreviation can result in unreliable medical reports and potentially affect the overall outcomes. Fortunately, accurate medical transcriptions can help ensure that patient records are thorough. 

So, what are the most commonly used medical abbreviations that transcriptionists need to familiarize themselves with, and how can mastering them contribute to providing exceptional service?

In this article, you’ll learn how:

  • Medical transcriptionists turn spoken medical reports into written documents. They help make sure that patient records are accurate.
  • Transcriptionists need to know common medical abbreviations well. This helps them avoid mistakes that could affect patient care.
  • Using correct medical terms is important for healthcare workers to communicate clearly. When everyone uses the same terms, it’s easier to work together.

What is Medical Transcription?

Medical transcription is the process of converting voice-recorded medical reports dictated by healthcare professionals into written or electronic text. 

In this process, the doctor, nurse, or medical practitioner records relevant information through dictation. The audio file is then sent to a medical transcriptionist, who transcribes it into written or electronic form, as the client requires. 

Once the audio is transcribed, the transcript is sent through a review process (the quality and rigor of which depends on the transcriptionist or provider) to catch any errors and ensure clarity and adherence to medical standards. 

After that, the transcript is formatted according to the templates or guidelines so that they can fit into electronic health records (EHR) or electronic medical record (EMR) systems. 

Settings Where Medical Transcription Is Crucial

Now that you’ve tackled the definitions, below are some of the most common settings where medical transcriptions can be beneficial.

SettingDescription
HospitalsWhere doctors and nurses work round-the-clock to treat patients, dictating notes and reports that medical transcriptionists carefully document.
Clinics and Private PracticesYour local doctor’s office or specialist’s practice, where a healthcare worker dictates notes about your visits, treatments, and referrals.
Diagnostic CentersFrom X-rays to blood tests, these centers have transcriptionists who precisely document the specialists’ findings and recommendations.
Surgery CentersMedical workers document operative reports before, during, and after your surgery to ensure a complete procedure record.
Emergency DepartmentsMedical transcriptionists can quickly and accurately document patient encounters, triage notes, and treatment plans to keep up with the urgency.
TelemedicineAs virtual doctor visits become more common, transcriptionists can help document these remote consultations and follow-ups.
Medical ResearchBehind the scenes of medical breakthroughs, transcriptionists help document research findings, study protocols, and grant applications. 
Insurance CompaniesInsurance companies often use accurately transcribed medical records to process claims and manage cases.
Legal SettingsMastically transcribed medical records can make all the difference in legal cases involving medical malpractice, personal injury, or disability claims.

List of Commonly Used Medical Abbreviations &  Acronyms that Transcriptionists Must Know

There are quite a number of medical abbreviations in English alone. Below is a list of the most common abbreviations that medical transcriptionists are familiar with. 

  • FUO – fever of unknown origin
  • JVP – jugular venous pressure
  • ORIF – open reduction and internal fixation
  • SFA – superficial femoral artery
  • CPS – Child Protective Services
  • RBC – red blood cell
  • CBF – cerebral blood flow
  • WDWN – well developed, well nourished
  • TM – tympanic membrane
  • BMI – body mass index
  • LLQ – left lower quadrant
  • PPD – Postpartum Depression
  • ICP – intracranial pressure
  • TIA – transient ischemic attack
  • ABG – arterial blood gas
  • OT – occupational therapy
  • MCL – medial collateral ligament
  • JVD – jugular venous distention
  • FNA – fine needle aspiration
  • CBD – common bile duct
  • EEG – electroencephalogram
  • NPO – nothing by mouth (Latin: nil per os)
  • LMP – last menstrual period
  • ADR – adverse drug reactions
  • IDDM – insulin-dependent diabetes mellitus or type 1 diabetes
  • DC – discharge OR discontinue
  • DPT – daily physical therapy
  • DNR – do not resuscitate
  • TAB – tablet
  • IBS – irritable bowel syndrome
  • QID – four times a day (Latin: quater in die)
  • NICU – neonatal intensive care unit
  • HEENT – head, eyes, ears, nose, throat
  • VF – ventricular fibrillation
  • A&O – alert and oriented
  • PIV – peripheral intravenous
  • UPJ – ureteropelvic junction
  • KUB – kidney, ureter, bladder (X-ray)
  • SOB – shortness of breath
  • GTT – glucose tolerance test
  • BKA – below-knee amputation
  • WBC – white blood cell count
  • RUQ – right upper quadrant
  • RBBB – right bundle branch block
  • PCP – primary care physician
  • CABG – coronary artery bypass graft
  • GCS – Glasgow coma scale
  • BS – blood sample
  • MRI – magnetic resonance imaging
  • NAD – no abnormality detected
  • HIV – human immunodeficiency virus
  • VS – vital signs
  • EKG – electrocardiogram
  • URI – upper respiratory infection

Note: Transcriptionists can use abbreviations in reports even when the full term is dictated to avoid lengthy sentences. However, knowing when to use abbreviations and understanding the formatting rules is as important to avoid misinterpretations.

Importance of Accurate Medical Terms and Abbreviations

Medical terminology is important, and it can be a difficult concept for aspiring healthcare professionals, including transcribers. Indeed, the terminology is filled with abbreviations, terms, and complex words, including medical coding and medical billing in some record types. 

However, this is all necessary. Healthcare personnel use medical terminology to ensure everyone understands all the information in different patients’ medical records. Moreover, standardizing medical terminology helps facilitate effective healthcare communication among healthcare providers globally. 

Medical abbreviations make it faster for physicians to dictate or note important details for histories and medical procedures. For example, medical practitioners and employees in the healthcare industry, including those who work in transcription, must learn medical terminology to operate as safely and efficiently as possible. 

How Transcription Services Can Help With Medical Abbreviation Issues

Skilled medical transcriptionists are trained to correctly interpret common medical abbreviations, which reduces the risk of misinterpretation. 

However, even the best transcriptionists may struggle to accurately transcribe the information when abbreviations are used incorrectly, which can lead to errors in the final medical record.

That’s why finding the best medical transcription service provider to meet your needs is critical. 

And wouldn’t you know it, you’re already looking at the best. 

Benefits of Choosing Ditto As Your Reliable Medical Transcription Services

Here’s why Ditto is your best choice for medical transcription. 

Time Savings

According to a recent report, orthopedic surgeons spend, on average, 14 hours per week on paperwork and 9 hours on EHR documentation. Administrative staff also spend hours organizing details, assigning codes, filling forms, and handling other record-keeping tasks. 

Transcription services eliminate the need for manual documentation by reducing paperwork time. For example, doctors, nurses, and other support staff can provide verbal accounts and recordings. Then, a professional medical transcriptionist who understands medical terminology can take over the process and provide accurate transcription. 

Cost Efficiency

Hiring in-house medical transcriptionists for the job is also very expensive. Hiring costs, salaries and benefits, equipment, and office space expenses can cost as much as $100,000 per year per transcriptionist.

Outsourcing your transcription to a reliable medical transcription provider like Ditto lets you reduce in-house costs by as much as 60%. Medical facilities looking to streamline their documentation process will be hard-pressed to find a more cost-effective way than outsourced transcription solutions. 

Accuracy

Medical providers are well aware of the headaches of paperwork and documentation. Indeed, documentation of medical records is a difficult multi-step process, and any issue can negatively affect the whole procedure. Thankfully, any concern with documentation can be addressed with one solution: accuracy

One of the most valued advantages of medical transcription is its accuracy guarantees. For example, our medical transcription team works on your audio files, produces the most accurate transcripts possible, and ensures that grammar and spelling are all correct and that every nugget of information is taken down and placed in its proper field. 

You might have run across AI transcription services in your hunt. While new and relatively popular, there are better options for accurate medical transcription than AI. 

According to a recent study, AI transcription is, at best, 86% accurate, while manual transcription providers like Ditto can reach more than 99% accuracy for all projects. 

Consistency in Documentation

Consistent medical transcription from quality providers can help improve record standardization procedures outside EMR/EHR systems. Uniform records take the guesswork out of paperwork, enhance readability, and improve data structure so doctors and other private health professionals can peruse records with little fuss. 

In this case, healthcare industry professionals are encouraged to enlist the services of a reliable transcription company, like Ditto Transcripts, to handle their medical data. 

Compatibility With EHR/EMR

EHR and EMR systems require medical staff to input patient information into designated boxes. Theoretically, this should speed things up. However, that depends on the user’s level of skill and experience. 

Reliable outsourced medical transcription providers like Ditto Transcripts can interface with almost every EHR system on the market. We can take the documentation burden out of your hands, allowing physicians to focus more on their patients and live more outside work.

Here’s how we do it.

  1. Doctors, nurses, and medical staff dictate patient information, chart notes, histories, treatment plans, medication, and other relevant EHR data.
  2. Audio recordings are sent to us via our secure cloud interface.
  3. We assign a skilled medical transcriptionist to produce and proofread the transcripts. Transcribed dictations are converted into PDFs, RTFs, or other text file formats as required.
  4. We send the completed work back to you. The transcripts, formatted into structured EHR templates, allow your system to read and auto-populate proper text fields using an HL7 interface.
  5. What’s more, you don’t need to worry about regulatory issues. Ditto Transcripts complies with all HIPAA requirements, processes, and protocols to ensure your data is safe and secure. 

Outsource Your Medical Transcription Needs To Ditto

At Ditto Transcripts, we guarantee 99% accuracy rates for all medical transcriptions we provide to the healthcare industry, all delivered on time, every time. We offer affordable rates, flexible options, fast turnaround times, HIPAA-compliant security, and the best customer service in the industry. 

Ditto Transcripts is a HIPAA-compliant, Denver, Colorado-based transcription company that provides fast, accurate, and affordable transcription services for hospitals, clinics, facilities, and individual practices of all sizes. Call (720) 287-3710 today for a free quote, and ask about our free five-day trial.

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