12.5 Basic Medical Shorthand
Katie Baker
The ability to quickly and accurately document patient-provider interactions is one of the most crucial skills for healthcare professionals. By using medical shorthand, providers can simultaneously record visits and patient conversations. It is essential to use approved abbreviations to ensure clarity and prevent misinterpretation or medical errors. These abbreviations are often approved by professional organizations, but individual medical institutions may also publish their own lists of accepted terms.
Terms Relating to Anatomy and Physiology
Historically, professional medical terminology was developed to enable precise communication among healthcare providers. However, it also served a gatekeeping function, making it harder for the general public to understand the concepts discussed. In the early days of human anatomical exploration in Western society, higher education was provided in Latin and Greek and limited to white men of higher socioeconomic standing. As a result, many anatomical and physiological terms used today are derived from Latin or Greek roots.
Additionally, some medical terms were named after Western men who were credited with “discovering” certain body parts or conditions. Today, many of these terms are being renamed to be more descriptive and inclusive of various backgrounds. For example, the sphincter of Oddi, located in the duodenal wall and responsible for the secretion of pancreatic juices and bile, is now referred to as the hepatopancreatic sphincter to more accurately reflect its origins in the liver (hepato-) and pancreas.
More recent language changes, such as the shift away from person-first language for autistic individuals and the movement toward gender-neutral terms to be more inclusive of transgender people, have also improved communication between healthcare providers and patients. For instance, the term “women” has traditionally been used to refer to people with uteruses. However, this terminology can exclude trans men with intact uteruses and misrepresents individuals who are cisgender women post-hysterectomy or trans women. As medical communication evolves, the use of inclusive and accurate language is becoming more common.
In the healthcare field, there is also a growing shift towards using lay language, or common terms, when discussing anatomy and physiology with patients. This practice helps ensure that patients better understand their health. However, medical terminology remains crucial in charting or when communicating with other healthcare providers to ensure clear, precise understanding.
In Appendix 8, you will find a table of common regional and systemic anatomical terms along with their definitions. The table highlights the use of Greek and Latin prefixes to describe different body systems, helping you decode unfamiliar terms by understanding the root words that categorize them.
A system using abbreviations and symbols to take written or typed notes more rapidly.