Common ER abbreviations for chartingRegister Today!
- by cathyrn2b Aug 29, '12Hello, I'm a new grad in the ER and was wondering if any of you could give me common abbreviations used in the ER charting? When charting my initial assessment I feel like I'm spelling everything word for word and it's taking me longer. Any suggestions would be greatly appreciated.
- Aug 30, '12 by iluvivtMost hospitals have an approved list of abbreviations. So go to you policy Manuel locate it and print it for your clipboard. That way if you ever need your charting to support your action your documentation will be clear, In a lawsuit they can get that approved abbreviation list or if there is an incident report they will understand your charting.
- Aug 30, '12 by Christy1019Wctm = will continue to monitor
NSR - Normal sinus rhythm
ST - Sinus tachycardia
RBBB/LBBB - right and left bundle branch block
PIV - peripheral i.v.
S/L - saline lock aka heplock
CP- Chest pain
Sob - short of breath
DIB - diff. In breathing
IVDA - intravenous drug abuse
NTG SL - nitroglycerin sublingual
C/O - complains of
If I think of more I'll post them
- Aug 31, '12 by Christy1019Quote from emtb2rnLol i love it, don't know how to use most of em but still love em!gomer - get out of my er
tstl - too stupid to live
ctd - circling the drain
tntc - too numerous to count (useful when charting a cutter)
echphm - extra cheese half pepperoni half mushroom
sk/ft - slip knot into franklin's tower
- Aug 31, '12 by Esme12GOMER is from the book....The house of GOD! They are not approved abbrevations for charting but are used in the lingo with each other.
YOu might find this interesting.The House of God - Wikipedia, the free encyclopedia
- Sep 1, '12 by brainkandy87s/p = status post (I swear, it took me forever to learn this.. I'd always forget what it stood for)
ETOH = ETOH. Or, alcohol.
d/t = due to
r/t = related to
pt = patient
gtt = drip
- Sep 2, '12 by JBudda&ox4 = alert and oriented to person, place, time and situation
NAD = no acute distress
CTA = clear to auscultaion
+BSx4 = bowel sounds present in all 4 quadrants
FROMx4 = full range of motion in all 4 extremities
MAE = moves all extremities
CR<2 = capillary refill less than 2 seconds
BKA = below the knee amputation
AKA = above the knee amputation
IDDM = insulin dependent diabetes mellitus
NKDA = no known drug allergies
PERRLA = Pupils equal round, reactive to light and accomadating
RAMs intact = capable of rapid alternating movements (neuro)
- Sep 5, '12 by rncindyoCTA also means "catt scan angio" so be sure to check for correct usage of this one.
BS is used for Bowel sounds or Breath sounds,
due to the dual meanings of many abbreviations, it may be wisest to follow the first advice
and check for policy at your facility, seek out a list of their approved abbreviations
before using ones suggested here. Not all are universal anymore.
- Sep 5, '12 by psu_213Definitely go with the abbreviation list for your facility. For instance at one facility for which I worked: Rt. was right...had to be capitalized and have the period. R/T was related to...capitalized with the slash. RT (again, capitalized) was respiratory therapy. Other places I've worked does not have the abbreviation for respiratory therapy.
Point is, abbreviations need to be precise and they can vary from place to place.