Clinical Doc Abbreviations
0Mar 22, '09 by howsoonMy clinical instructor wants us to use the proper abbreviations in our clinical paperwork. Problem is we haven't really learned this. Can anyone point me to a website with this info? I'm looking for things as simple as N/V/D.
0Mar 22, '09 by SolaireSolsticeDid your clinical instructor say you HAD to use abbreviations? Or did your clinical instructor say IF you use abbreviations, make sure they are the correct clinical abbreviations?
The only reason I ask is because there are abbreviations for just about everything, and some are no longer "JCAHO" approved, but the MDs still use them. (such as QD and MS) Those should be clarified with the MD (by the nurse) if written in an order.
My personal suggestion is do not use ANY abbreviations until/unless you know what they stand for and you know they are approved.
I did find a list of the unapproved JCAHO appreviations. These are ones you should NOT use, but I see them in nursing school all the time.
These are websites I found that have "common" medical abbreviations. Some of these I have never seen used before, and I've worked in medical offices and hospitals for 20 years.
And no matter how "simple" the abbreviation may seem, if you aren't sure, just ask (NEVER guess). I get MDs abbreviating all sorts of labs and exams and diagnosis all the time and although I've been inputing orders for years, they still find a new way to stump me.Last edit by SolaireSolstice on Mar 22, '09 : Reason: clarification
0Mar 26, '09 by JolieYou've got to be careful with this, because every health care agency/institution must, per JCAHO standards, create their own list of approved abbreviations.
JCAHO has identified some abbreviations that are not to be used, but hasn't provided a list of acceptable ones. That varies from hospital to hospital and agency to agency.
You need to know what is acceptable at the clinical site, and not assume that the same abbreviations are OK at the next place you go for clinical.
0Mar 26, '09 by Heogog53Most hospital publish a list of THE prohibited abbreviations and then a list of approved ones. As far as I know, my current hospital teaches the residents/interns/medical students the proper ones because we are on computerized Physician's Orders, which forces them to adapt.
Always question any abbreviation that you don't understand. I think your instructor is actually doing you a disservice by insisting that you abbreviate as much as possible. That could become a real legal liability issue if something were to happen and the notes were part of discovery. Then you might get a subpeona years later to come on down and translate them, plus being asked by the opposing lawyer something like, "Well, nurse so and so, are you aware that the following abbreviations are prohibited by Joint Commission? So why did you use those abbreviations? Etc."
A friend of mine worked for a doc as a private scrub. Because certain patients were considered Pains in the Ass, their office has a little abbreviation for them which was "PIA". When the doc's records were audited, several of the staff were asked exactly WHAT a PIA abbreviation meant. Thinking quickly, she told them that it meant Patient Waiting in Alcove(there were two alcoves). This happened in the 90's. It scared the staff enough that the use of said abbreviation was retired for good.
So be careful what and how you abbreviate. For this course, I guess, you have to play the instructor's game- unless you can go to the instructor or to the Department Head with those great websites and some research into "good abbreviations" vs "bad abbreviations". Your instructor should have given you a list, first of all, and should not be insisting that you use as many creative ways to abbreviate in your notes.