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ShortNote Clinical Shorthand

Richard Rathe, September 2016

I have worked with home-grown and commercial Electronic Medical Records for over thirty years. The use of dot commands (a period followed by a trigger phrase) is about as old as personal computing. (I first encountered dot commands in the WordStar word processing program during the 1980s!) These commands generally fall into three categories:

links to retrieve data (name, age, lab values, etc.)
links to specialized services or applications
macros that expand into canned text

While working on a new set of macros for my Rational HPI Project, it struck me that all those periods were getting in my way. (I can touch type but special characters generally slow me down.) This is particularly true when using many short fragments. I decided to experiment with a standardized clinical shorthand based on these criteria:

Include common abbreviations when they exist.
Expand common but potentially dangerous abbreviations into plain text (qd, qod, etc. are often banned in written notes).
Make the triggers (aka shorts) as mnemonic as possible.
Limit punctuation and the need to use modifier keys (i.e., shift, alt, control, etc.). This is especially important for handheld devices such as tablets and smartphones.
Prevent transformation of non-shorthand text. (A paragraph of plain text should generally pass through unchanged.)

Clinical Shorthand v1.1

My first attempt resulted in approximately 200 shorts. The revised list is presented here. Note that the goal is to generate functional documentation with the fewest keystrokes, not flowing paragraphs.

Typing all lower-case is assumed but not required. Capitalization is only enforced for canonical abbreviations (HPI, ROS, RUQ, etc.) and certain keywords that are frequently missed (NO, NOT, LEFT, RIGHT).

Punctuation is optional and should be kept to a minimum. How much punctuation to add automatically is an unsettled issue. At this time I include colons when a list is expected and commas for certain qualifying phrases. This is subject to change.

Finally, certain phrases are included to support the needs of billing and compliance.

In the tables below '99' indicates any number and time 'i' indicates m(i)nutes. Other time units are what you'd expect. Changes from v1.0 are indicated by '‡' in the comments.

Prolog

99yf	99 year old female	‡
99ym	99 year old male	‡
hx	history of
cc	presents with
ccn	presents with new
cco	presents with onging
ccc	presents with chronic

Time

s=sec i=min d=day w=week m=mon y=year

0d	a few days	0 = a few
99d	99 days
99xd	99 times a day	synonym
x99d	99 times a day	‡
e99d	, episodes lasting 99 days
s99d	, started 99 days ago

Time (Latin Derived)

qd	daily
bid	twice daily
tid	three times daily
qid	four times daily
qod	every other day
ac	before meals
pc	after meals
hs	at bedtime

Location

l	LEFT
r	RIGHT
ls	LEFT-sided
rs	RIGHT-sided
bi	bilateral
ce	central
df	diffuse
an	anterior
po	posterior
me	medial
la	lateral
luq	LUQ
ruq	RUQ
llq	LLQ
rlq	RLQ
eg	epigastic
pu	periumbilical
sp	suprapubic
rad	, radiates to
nrad	, NO radiation	‡

Onset (os)

os	onset
osg	gradual onset
osi	insidious onset
oss	sudden onset

Progression (pg)

pgu	, unchanged
pgr	, resolved
pgv	, comes and goes	v = variable
pgb	, gradually getting better
pgbr	, rapidly getting better
pgw	, gradually getting worse
pgwr	, rapidly getting worse

Severity (sv)

svi	mild
svm	moderate
svs	severe
sv9	9 out of 10
sva	, an annoyance	functional for 'mild'
svh	, a hindrance	functional for 'moderate'
svd	, disabling	functional for 'severe'

Symptoms (sx)

sx	symptom	sxs plural
sxa	associated symptoms:	list
sxn	pertinent negatives:	list
sxr	associated symptoms (see ROS)	include ROS in HPI for billing
sxo	all other relevant systems are negative	include ROS in HPI for billing

Common Symptoms

sob	shortness of breath
co	productive cough
uc	unproductive cough
bc	bloody cough
wz	wheezing
itc	itching
ns	nausea
vm	vomiting
nv	nausea and vomiting
pn	pain
cp	chest pain
jp	joint pain
mp	muscle pain
fp	flank pain
up	upper extremity pain
lp	lower extremity pain
ap	abdominal pain
np	neck pain
bkp	back pain
bkl	lower back pain
bku	upper back pain
ha	headache
ep	eye pain
ei	eye itching/discomfort
vc	visual changes
hbp	high blood pressure
lbp	low blood pressure
bp	blood pressure
hbs	high blood sugar
lbs	low blood sugar
bs	blood sugar
uts	urinary symptoms
ra	rash
ir	itchy rash
rr	red rash
rsr	red scaly rash
rir	red itchy rash
fv	fever
di	diarrhea
cn	constipation

Common Diseases

pd	lung disease
hd	heart disease
kd	kidney disease
ld	liver disease
gd	gallbladder disease
prd	prostate disease
hf	heart failure
mi	heart attack
pe	pulmonary embolism
htn	hypertension
ath	asthma
obs	obesity
dm1	type 1 diabetes
dm2	type 2 diabetes
dm	diabetes
hl	hyperlipidemia
htt	hyperthyroidism
ht	hypothyroidism
dep	depression
anx	anxiety
ca	cancer
uti	urinary tract infection	utis plural
ger	gastro-esophageal reflux
bph	BPH
chf	CHF
ckd	CKD
copd	COPD
gerd	GERD
hiv	HIV

Miscellaneous

px	problem	pxs plural
lx	lab test	lxs plural
rx	prescription	rxs plural
mx	medication	mxs plural
tx	treatment	txs plural
otc	OTC medication	otcs plural
stx	self-treatment
ptx	physical therapy
otx	occupational therapy
rtx	respiratory therapy
pt	patient
pts	patient's
ds	disease
sd	syndrome
ed	emergency department
er	emergency department	synonym
hsp	hospital
dc	discontinue
dch	discharge
prn	as needed
xr	xray
cxr	chest xray
ct	CT Scan	‡
mri	MRI	‡
usi	ultrasound	‡
im	imaging
ekg	EKG	‡
rf	risk factors:	list
ka	allergies:	list k = known ‡
nka	NO known allergies	‡
nkda	NO known drug allergies
hpi	HPI
ros	ROS
pmh	PMFSHx	past med/fam/soc history
pmhr	relevant past medical, family and social history reviewed with the patient
src	history from	‡
srcp	history from patient	‡
arnp	ARNP	‡
md	MD	‡
rn	RN	‡

Modifiers

un	unknown
nl	normal
ab	abnormal
eq	equal
ue	unequal
vr	variable
rc	recent	‡
gt	greater than
lt	less than
ag	aggravated by
tg	triggered by
rl	relieved by
apx	approximately	‡

Smoking (sm)

smn	never smoker
smk	current smoker
smk99	current smoker, 99py history
smf	former smoker
smf99	former smoker, 99py history
smq	current smoker, ready to quit, discussed smoking cessation
smq99	current smoker, 99py history, ready to quit, discussed smoking cessation
smc	current smoker, discussed smoking cessation
smc99	current smoker, 99py history, discussed smoking cessation

Single Letter Connectors

Note 'a' and 'i' have been replaced. ‡

b	before	‡
c	with	Latin 'cum'
e	and	Latin 'et'
f	from
n	NOT
p	after	Latin 'post'
s	without	Latin 'sine'
w	within	‡
x	except

Units

99u	99 units
99iu	99 international units

Negation

Note the minus '-' form has been replaced. ‡

capitalized for emphasis

Alphabetical Listing

0d	a few days	0 = a few
99d	99 days
99iu	99 international units
99u	99 units
99xd	99 times a day	synonym
99yf	99 year old female	‡
99ym	99 year old male	‡
ab	abnormal
ac	before meals
ag	aggravated by
an	anterior
anx	anxiety
ap	abdominal pain
apx	approximately	‡
arnp	ARNP	‡
ath	asthma
b	before	‡
bc	bloody cough
bi	bilateral
bid	twice daily
bkl	lower back pain
bkp	back pain
bku	upper back pain
bp	blood pressure
bph	BPH
bs	blood sugar
c	with	Latin 'cum'
ca	cancer
cc	presents with
ccc	presents with chronic
ccn	presents with new
cco	presents with onging
ce	central
chf	CHF
ckd	CKD
cn	constipation
co	productive cough
copd	COPD
cp	chest pain
ct	CT Scan	‡
cxr	chest xray
dc	discontinue
dch	discharge
dep	depression
df	diffuse
di	diarrhea
dm	diabetes
dm1	type 1 diabetes
dm2	type 2 diabetes
ds	disease
e	and	Latin 'et'
e99d	, episodes lasting 99 days
ed	emergency department
eg	epigastic
ei	eye itching/discomfort
ekg	EKG	‡
ep	eye pain
eq	equal
er	emergency department	synonym
f	from
fp	flank pain
fv	fever
gd	gallbladder disease
ger	gastro-esophageal reflux
gerd	GERD
gt	greater than
ha	headache
hbp	high blood pressure
hbs	high blood sugar
hd	heart disease
hf	heart failure
hiv	HIV
hl	hyperlipidemia
hpi	HPI
hs	at bedtime
hsp	hospital
ht	hypothyroidism
htn	hypertension
htt	hyperthyroidism
hx	history of
im	imaging
ir	itchy rash
itc	itching
jp	joint pain
ka	allergies:	list k = known ‡
kd	kidney disease
l	LEFT
la	lateral
lbp	low blood pressure
lbs	low blood sugar
ld	liver disease
llq	LLQ
lp	lower extremity pain
ls	LEFT-sided
lt	less than
luq	LUQ
lx	lab test	lxs plural
md	MD	‡
me	medial
mi	heart attack
mp	muscle pain
mri	MRI	‡
mx	medication	mxs plural
n	NOT
nka	NO known allergies	‡
nkda	NO known drug allergies
nl	normal
no	NO	capitalized for emphasis
np	neck pain
nrad	, no radiation	‡
ns	nausea
nv	nausea and vomiting
obs	obesity
os	onset
osg	gradual onset
osi	insidious onset
oss	sudden onset
otc	OTC medication	otcs plural
otx	occupational therapy
p	after	Latin 'post'
pc	after meals
pd	lung disease
pe	pulmonary embolism
pgb	, gradually getting better
pgbr	, rapidly getting better
pgr	, resolved
pgu	, unchanged
pgv	, comes and goes	v = variable
pgw	, gradually getting worse
pgwr	, rapidly getting worse
pmh	PMFSHx	past med/fam/soc history
pmhr	relevant past medical, family and social history reviewed with the patient
pn	pain
po	posterior
prd	prostate disease
prn	as needed
pt	patient
pts	patient's
ptx	physical therapy
pu	periumbilical
px	problem	pxs plural
qd	daily
qid	four times daily
qod	every other day
r	RIGHT
ra	rash
rad	, radiates to
rc	recent	‡
rf	risk factors:	list
rir	red itchy rash
rl	relieved by
rlq	RLQ
rn	RN	‡
ros	ROS
rr	red rash
rs	RIGHT-sided
rsr	red scaly rash
rtx	respiratory therapy
ruq	RUQ
rx	prescription	rxs plural
s	without	Latin 'sine'
s99d	, started 99 days ago
sd	syndrome
smc	current smoker, discussed smoking cessation
smc99	current smoker, 99py history, discussed smoking cessation
smf	former smoker
smf99	former smoker, 99py history
smk	current smoker
smk99	current smoker, 99py history
smn	never smoker
smq	current smoker, ready to quit, discussed smoking cessation
smq99	current smoker, 99py history, ready to quit, discussed smoking cessation
sob	shortness of breath
sp	suprapubic
src	history from	‡
srcp	history from patient	‡
stx	self-treatment
sv9	9 out of 10
sva	, an annoyance	functional for 'mild'
svd	, disabling	functional for 'severe'
svh	, a hindrance	functional for 'moderate'
svi	mild
svm	moderate
svs	severe
sx	symptom	sxs plural
sxa	associated symptoms:	list
sxn	pertinent negatives:	list
sxo	all other relevant systems are negative	include ROS in HPI for billing
sxr	associated symptoms (see ROS)	include ROS in HPI for billing
tg	triggered by
tid	three times daily
tx	treatment	txs plural
uc	unproductive cough
ue	unequal
un	unknown
up	upper extremity pain
usi	ultrasound	‡
uti	urinary tract infection	utis plural
uts	urinary symptoms
vc	visual changes
vm	vomiting
vr	variable
w	within	‡
wz	wheezing
x99d	99 times a day	‡
x	except
xr	xray

Disclaimer

I did the original development of ShortNote while on the faculty of the University of Florida. I make no claim of copyright and consider these ideas to be in the public domain. I also make no claim of suitability for purpose and accept no liability for same.

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