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:
no CVA tenderness
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.
Oct 14, '08
Quote from cozzy66
especially if it were come to my notes being read in court.
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.
Last edit by Balder_LPN on Oct 14, '08