Triage and Assessment Abbreviation

[PMHNP2023]

I am a new grad to the ED and have come across some abbreviations when reading ED Triage notes and ED Assessments specifically. I'd like people to add more to the list, to hopefully create a more comprehensive list of abbreviations, as I only know a few of them.

abx - antibiotics

bibm - brought in by medic

c/c - chief complaint

c/o - complaint of

perrl - pupils equal round reactive to light

pms - pulse, motor, sensory

sob - shortness of breath

s/p - status post

vss - vital signs stable

[Bubbles]

This system is not working properly. My apologies to the person who did enter the post.

[TraumaSurfer]

Anytime someone has to use Google to read your charting, you probably are not using standard abbreviations.

The last time I actually saw BIBM used in an acute medical setting was in the 80s to identify high risks for HIV. Medic is also a shortened term in the civilian world for Paramedic.

Your hospital should have and approved list of abbreviations and the national DO NOT use list since this is on the JACHO surveys.

[edmia, BSN, RN]

BIBEMS: Brought in by EMS

MAEW: moves all extremities well

CAD: coronary artery disease

N/V/D: nausea, vomiting, diarrhea

2/2: secondary to

c/b: complicated by

PMH: previous medical history

PSH: previous surgical history

A&Ox4: alert and oriented to person, place, time, and situation

Tx: treatment

AAA: abdominal aortic aneurysm

HI5: HIV +

... this is a list of things commonly used/seen. I'm not saying they SHOULD be used. In order to properly communicate, all words should be spelled out.

[FranEMTnurse, CNA, LPN, EMT-I]

I was an active EMT for 18 years and we used several abbreviations that were standard protocol. However nursing does use sever more.

[PMHNP2023, RN]

PMS intact - pulse motor sensory

MAEx4 = moves all extremities

[turnforthenurse, MSN, NP]

APAP = Tylenol

NTG = nitroglycerin

SL = sublingual

NAD = no acute distress

SOB = shortness of breath. I have also seen SOA = shortness of air but it's not as common.

C/O = complain of

CC = chief complaint

[psu_213, BSN, RN]

HI5: HIV +

... this is a list of things commonly used/seen. I'm not saying they SHOULD be used. In order to properly communicate, all words should be spelled out.

Not so much directing this at you, but at people who use the "abbreviation"...why would you put the slang for HIV in the chart? It is an official record, it's not for everyone to read, and typing HI5 saves you a whole one keystroke as compared with HIV+. If others (i.e. those not involved with the pt's care) are around, I would not use the slang since they might know what it means...to actually chart it really makes no sense either.

[Anna Flaxis, BSN, RN]

BIBA=Brought In By Ambulance

P/W/D=Pink, Warm, Dry

NAD=No Acute Distress

C/O=Complaint Of

Those are about the only abbreviations I use on a regular basis, and I'm pretty consistent about it. That is my understanding, is that if you are consistent about the way you chart, then even if it's years later and you're asked to review something you charted, you will be able to explain exactly what was going on with the patient because you are consistent in the way you document.