Terminology

Specialties Geriatric

Published

Specializes in LTC.

I am looking for some good resources and/or easy references to bring to work with me that would be helpful when it comes to terminology. I would like to improve on my charting by using more technical, professional, accurate wording, rather than "red spot, 1cm in size." I'd like a handy little tool to have with me at work. Thanks.

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Specializes in LTC,Hospice/palliative care,acute care.

Your employer will have a list of approved abbreviations for your use, they should also have a wound care policy, ours includes pictures and a word bank. That will get you started. I sometimes have to look up anatomy-I seem to have brain farts now and then and can't remember what something is called. And it's usually something dumb-I couldn't remember what the inner canthus was called a few weeks ago...

Your "red spot,1 cm in size" could read "circular shaped reddened area on (location) discovered during (bath,peri care,whatever) and address if it is blanchable Then address what you are doing for it-off loading pressure,skin prep.etc.. Read through other's progress notes as much as you can-they are a good teaching tool.

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Specializes in LTC, Memory loss, PDN.

fancy technical terms are not necessary for excellent charting

besides, when you say "red spot 1cm", everyone knows what to look for

and as a perk, you don't run the risk of coming across as diagnosing

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