Medical terms you'd rather see changed.... - page 7
I hate saying "expired" for someone who is dead and I could also do without seeing "morbid obesity" or even obese in the chart. I know being overweight is a serious health issue, but those words... Read More
Nov 24, '06Quote from mjlrn97LOLOL i have to admit there are times i woner if it isnt a prison sentence HAHAHA - kidding - i agree - really does sound bad to "confine " vs actually say due date lol.Confinement sounds like a prison sentence instead of one of life's greatest events. Lose it!
Nov 24, '06Quote from RNHawaii34in my former workplace they used " A/O3X.NSR w/BBB.......I am a newbie, I hate it when they make their own abbreviations! hx, sx, tx? as in texas?
most places have standard approved abreviations - usually taught in school as well - alert and oriented times three meaning to time place and person - normal sinus rythym , bundle branch block, however many are getting away and encouraging full written words due to some abreviations are to similiar casuing errors to happen.
Nov 24, '06Quote from tvccrnLOL there are times though i DO fel like geriatric maternal age LOL. and dh will tell you i act that way at times too - butyeah it does sound nasty.I'm 39 and have been labeled with "geriatric maternal age". I could have handled advanced, but GERIATRIC, come one!!
Nov 24, '06I've seen similar assessment shorthand.
A/Ox3 RSR /s (M)BSP af /s AS----------circle around the m
Alert, Oriented times 3
Regular Sinus Rhythm Without Murmur,
Breath Sounds Present All Fields Without Adventitious Sounds.
But just think what a mess that would be defending in court.
Nov 24, '06Re the compliance/noncompliance issue: It would be helpful if the writer were to specify "was unable" or "was unwilling" to comply with...
Nov 25, '06Quote from JamesdotterGood call. I think that's a very sensible and much more helpful alternative to the ridiculously PC "non adherence", which achieves nothing more than the term "non compliance" anyway.Re the compliance/noncompliance issue: It would be helpful if the writer were to specify "was unable" or "was unwilling" to comply with...
Nov 25, '06Quote from steve0123I don't know, I deal with a LOT of NONCOMPLIANT ppl in my practice. Ppl with C fractures ordered BR/HOB30degrees that refuse to comply. Gangbangers that purposely try to give themselves an infection in their GSW because they don't want to leave the hospital. Yeah, I'll still use non-compliance and refusal in my practice. I don't need extra words to right like refuses to or unable to. I don't really run into "unable to" in my practice. "Pt. is non-compliant" is and will continue to be used in my charting.Good call. I think that's a very sensible and much more helpful alternative to the ridiculously PC "non adherence", which achieves nothing more than the term "non compliance" anyway.
Pulmonary toilet though :trout:
Nov 25, '06If you don't like the abbreviations or terms, just stop using them. Eventually someone will ask why, and when you explain, you may convert them and you'll start your own revolution. As to expire, I assume it comes from the last 'expiration'. But when I have to tell a loved one this news, I just say I'm sorry to have to tell you that (Mom/Dad etc.), has passed over. Then I add that I'm sorry for their loss. As to the abbreviations, JCAHO doesn't allow some of them anymore. Let me tell you why I stopped using them years ago. As a (then) registry nurse, I had to be extra careful to do things correctly since it's often difficult in a new situation with no orientation. I had five different eye drops to give someone and could not find the fifth. I had the right bottle, but the order on the bottle, didn't match the MAR. I finally went to the chart. The doctor ordered all the drops 'OD qid'. Except the last one. It was 'OD OD'. The nurse who transcribed the order didn't, as is human, see the double. She saw OD and assumed apparently that the doctor forgot to write qid. So the patient received the once a day drops four times a day...for six weeks! No one ever spotted it, meaning no one ever did the 5 rights. I know we're all overworked, underappreciated, and exhausted most of the time...but think how many nurses that is. Well, that nurse got a transcription error, the family took the patient somewhere else, and me? Not even a thank you. So I thought that was a good reason to write things out. Now if we could just get the doctors to comply. Which, by the way, I do like the term non-compliant because of the refusal to listen to authority that it infers. If ever in court, I want the strongest words possible to show that the patient didn't listen to sound medical advice.
Nov 25, '06-diaper=briefs or underwear -refused= declined (w/ a brief explanation of why pt declined and noting that teaching was given re: importance of tx and possible consecquences; not to scare them into something they don't want, just to allow for informed consent and to explore alternatives) -non-compliant= never did know what to do w/ this one but I like "non-adherent" better MLast edit by melpn on Nov 25, '06 : Reason: poor spacing; it all kind of ran together
Nov 25, '06I don't like the "non-compliant" either. Sounds like a factory that refuses to abate their carbon monoxide or something.
WHat's wrong with "Mr S. states he cannot use the Incentive spirometer because he ______"
Mrs. J states she will not use the bedside commode because she wants to watch television &/or because she is afraid she will fall.......etc.
Nary a non-compliant there.
As for the eye drops did the pharmacy not catch the mistake? What about the nurse who checked off the orders?
Nov 25, '06Nightly chart checks never caught it. The order was hand written on the MAR at first and whoever prints up the new ones wrote what the nurse had transcribed instead of catching it on the POS. The inhouse pharmacy printed the order correctly on the label and that's the end of their involvement.
As for non-compliant, I like to use it when a patient has the attitude that we don't know what we're doing. But I always add the nurses note like the examples shown.
Nov 25, '06Unfortunately sometimes the term "non-compliant" assumes the roles of "refusing" in some people's minds, when in fact that may not be the case. I don't think it's specific enough.
I agree with the poster who brought up the terms "was unable" and "was unwilling." There's a difference between someone who has the means, yet refuses to care for themselves, and someone who doesn't have the means and therefore can't.
Nov 25, '06I regularly chart +BBSH CTA (positive B/L breath sounds heard, clear to auscultation) RRR (regular rate & rhythm). In court they ask for interpretation of med terms all the time, so as long as you're not making up your own, it's OK. But now that I see other posts, I do agree w/ "unable to" and "unwilling to" instead of "non-compliant" or "non-adherent" or at least as an explanation of why. Some very good points made here. M