Triage and Assessment Abbreviation
- 0Dec 21, '13 by CSUSM10I 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 stableLast edit by CSUSM10 on Dec 21, '13 : Reason: updated
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- 3Dec 22, '13 by Esme12 Senior ModeratorThe problem with hospital specific abbreviation is that hey don't belonging on the record. The Joint Commission has a specific list of approved abbreviations that are the only ones you use. If your facility allows thee abbreviations they need to make them official. Using unofficial abbreviations can lead to misunderstandings and mistakes.
These abbreviations above are ok except bibm...it should be..... patient arrived via Town A per EMS/ALS. bibm is not an approved abbreviation.
- 0Dec 22, '13 by chareQuote from Esme12Can you provide a link for this list? All that I have been able to find is their list of prohibited abbreviations.The problem with hospital specific abbreviation is that hey don't belonging on the record. The Joint Commission has a specific list of approved abbreviations that are the only ones you use. If your facility allows thee abbreviations they need to make them official. Using unofficial abbreviations can lead to misunderstandings and mistakes.
- 0Dec 22, '13 by psu_213Also, I only use VSS when I take a call from a LTC facility/medic/etc. and they specifically report that vital signs are indeed stable. If I take the vital signs, then I chart the actual vitals signs, not just VSS.
I have never heard of "BIBM." Also, I have always seen CSM (circulation, sensation, movement), not PMS. Perhaps they are approved by your facility...otherwise, stick with approved abbreviations.
- 1Dec 22, '13 by zmanscWith our EMR we have a place for vitals which is where the specific numbers go. If I'm writing a note and explaining why I performed a treatment or dc'ed the O2 or something else I will use VSS or hypertensive, or whatever describes the situation without putting in specific numbers. I do this as a way to limit the double documentation that is unfortunately a part of our medical record. This way, if the reader wants the specifics they can look them up, but they know why we did something and the big picture from the note. It also keeps me from having a typo in the note that now confuses people as to what the vitals actually were.
As for the rest of the thread, I would agree that the abbreviations should be a short list of approved abbreviations and I would have no clue what BIBM meant.
- 0Dec 22, '13 by CSUSM10Our facility does have an approved list (14 pages long!) of abbreviations. However, some people use abbreviations outside of the approved list. I started this post to see some of these "non-standard" abbreviations, not so I could use them, but so that I can decipher some of these triage notes I get from the front when getting a new patient.
- 2Dec 23, '13 by 1fastRNROM=Range of motion
AAOx3/A&Ox3=Alert and oriented x3
CP= Chest Pain
HA= Head ache
AMS=Altered mental status
N&V= Nausea and vomiting
LUQ,RUQ, etc= left upper quadrant, right, etc.
MVC=Motor vehicle crash
UTI=urinary tract infection
LOC=Loss of consciousness (also sometimes level of cons)
BG/BS= Blood glucose/blood sugar
A lot of these I use when quoting medics/patients/family
I see a lot of people use NAD=No acute distress. But I feel like that may be too subjective?
But agreed, most facilities have a list of approved abbreviations or atleast the unexceptable ones. I try to avoid a lot of abbreviations besides the more common ones.Last edit by 1fastRN on Dec 23, '13