My 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.
Mar 22, '09
Did 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