Nursing preceptor says no to certain abbreviations

Nurses General Nursing

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Hey all,

I know there are a number of threads regarding nursing abbreviations, but I think this one might be slightly different. I'm a new nurse, still on orientation. My preceptor has been telling me that I should not/can not use certain abbreviations, because other nurses don't know what they mean, especially if it were come to my notes being read in court. I have a hard time believing this, especially since the docs use these abbreviations in their notes and I assume RNs should be able to read MD notes and understand them.

Examples of what I've been told not to use:

S1S2 RRR

no CVA tenderness

CTA bilat

Is this reasonable? I have been meaning to get a list of acceptable abbreviations from my hospital, but haven't had the chance yet... any help is appreciated.

Thanks.

Specializes in ED, ICU, Heme/Onc.
I have always thought that your notes are your own personal property, and not a part of the medical (legal) record. not subject to all the same rules esp. regarding supeona.

The patient's chart is a legal document. Anything you write in the chart is discoverable. Which is why you would write a note about a patient being found on floor, your assessment and any action taken (called MD, pt. taken to CT...etc.) but you do not refer to the internal incident report document - that's not a part of the patient's chart.

HIH -

Blee

Specializes in Emergency & Trauma/Adult ICU.
I have always thought that your notes are your own personal property, and not a part of the medical (legal) record. not subject to all the same rules esp. regarding supeona.

In this discussion, "notes" means nurses' notes - entries in the chart.

Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.

I'm not sure what CVA tenderness is? It took me a minute to figure out CTA--I've seen it written LCTA, not just CTA. The main thing is that most hospitals are getting away from abbreviations. Probably in the future we aren't going to be using them at all. There is just way too much room for error. Especially with some nurses who I have worked with that have their own "made up" abbreviations. Stick to the most common ones and you should be fine. :)

Specializes in Gerontology.

To be honest, I don't what any of the abbreviations you put in your message mean.

CVA tenderness? To me, CVA is a Cardiovascular Accident - a stroke.

CTA? Circulation , touch? and A? _ not a clue.

I am assuming that S1S2 are heart sounds, but RRR? Again - no clue.

Think of it this way - if your pt were transferred to another hospital, would they understand these?

I know that sometimes we get pts admitted to our hospital from the USA and sometimes we have to play "what do you thing they meant" when reading the chart.

Specializes in Emergency & Trauma/Adult ICU.

CTA bilat = clear to auscultation bilaterally (as in, lungs)

RRR = regular rate & rhythm

Specializes in ER.

You do have to be aware that many of the abbreviations we tend to use mean different things in different areas of the hospital even. Also not everyone will know what you mean with the ones you use, docs are taught different abb than we are even. As long as your notes are clear it shouldn't be a big problem, however if the whole note is nothing but abbreviations people might not get the gist.

Specializes in Pediatric Psychiatry, Home Health VNA.

CVAT = costovertebral angle tenderness but to be honest I've never seen that used in a regular assessment unless the patient had something that warranted like pyelo or a stone.

Specializes in Day Surgery, Agency, Cath Lab, LTC/Psych.
CVAT = costovertebral angle tenderness but to be honest I've never seen that used in a regular assessment unless the patient had something that warranted like pyelo or a stone.

Thanks. I had no clue what that meant. It still doesn't make a whole lot of sense in the context of "tenderness." Why would we need to chart no CVA tenderness?

Thirty-five years ago we were taught to chart with the shortest amount of pen strokes, ie using abbreviations.

Having family and friends in the legal field, I do hear about different medical, malpractice and other aspects of some cases.

In todays world, there is a much greater chance that you will be going to court one day with regards to a patient that you have been involved with in some way. It is better to have the least amount of abbreviations possible, or preferably none at all.

Even if your abbreviation was correct, what about the person prior to you, who wrote an abbreviation that was not correct. Say you followed that person's abbreviation. Later (at court), you learn that you gave the patient the wrong/time of medication/dose/time- any of hundreds of different interpretation of an abbreviation, and now it is YOU that is being sued. Does that make sense?

In todays world, it is safer to write everything out- even in the small spaces provided.

Times are changing.

Specializes in Trauma, Teaching.

Our hospital has put out new policies, mostly pharmaceutically related, about acceptable abbreviations. A lot of the standard latin ones are no longer acceptable becuase of mistakes that have been reported (sentinal events). Things like QD must now be written out as daily, units written out instead of just "u". With sloppy handwriting (not that any doctor has poor penmanship!), QD can be misinterpreted as QID.

Our newest version of doctor's orders pages actually has the nonacceptable/acceptable abbreviations along the side of the page.

Somewhere in your hosp. policies and procedures book, there should be a list of approved abbreviations. (I almost wrote P&P ...... lol)

Specializes in Community, OB, Nursery.

We have our 'unapproved abbreviations' for docs on the order sheet as well, JBudd. We also have a book that lists acceptable abbreviations for the facility, and some were pretty surprising when I actually read through them (slow night, LOL).

Just as an aside, I have seen 'CVA tenderness' many times, mostly in MD dictations. They assess it if pt has sx of UTI. I don't use it as part of my assessment. I'm in mother/baby so don't really have a big need there most days.....

Specializes in ER/ medical telemetry.

abbreviations are always good because in the nursing world we are all pressed for time.

I do agree with many of the posters that abbreviations can vary from facility to facility. Most of the time there are abbreviations posted or listed in a designated place of ones that should not be used.

Yes, in a litagation if a abbreviation is not understood you may be asked what does it stand for? Hope one knows what they wrote from a couple years ago!

A pretty scary thought, but very good food for thought.

There are classes offered;of how to chart safely.

I will look for one of those classes.

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