Common ER abbreviations for charting

[cathyrn2b]

Hello, I'm a new grad in the ER and was wondering if any of you could give me common abbreviations used in the ER charting? When charting my initial assessment I feel like I'm spelling everything word for word and it's taking me longer. Any suggestions would be greatly appreciated.

[iluvivt, BSN, RN]

Most hospitals have an approved list of abbreviations. So go to you policy Manuel locate it and print it for your clipboard. That way if you ever need your charting to support your action your documentation will be clear, In a lawsuit they can get that approved abbreviation list or if there is an incident report they will understand your charting.

[Christy1019, ASN, RN]

Wctm = will continue to monitor

NSR - Normal sinus rhythm

ST - Sinus tachycardia

RBBB/LBBB - right and left bundle branch block

PIV - peripheral i.v.

S/L - saline lock aka heplock

CP- Chest pain

Sob - short of breath

DIB - diff. In breathing

IVDA - intravenous drug abuse

NTG SL - nitroglycerin sublingual

C/O - complains of

If I think of more I'll post them

[emtb2rn, BSN, RN, EMT-B]

gomer - get out of my er

tstl - too stupid to live

ctd - circling the drain

tntc - too numerous to count (useful when charting a cutter)

echphm - extra cheese half pepperoni half mushroom

sk/ft - slip knot into franklin's tower

[Christy1019, ASN, RN]

gomer - get out of my er

tstl - too stupid to live

ctd - circling the drain

tntc - too numerous to count (useful when charting a cutter)

echphm - extra cheese half pepperoni half mushroom

sk/ft - slip knot into franklin's tower

Lol i love it, don't know how to use most of em but still love em!

[Esme12, ASN, BSN, RN]

GOMER is from the book....The house of GOD! They are not approved abbrevations for charting but are used in the lingo with each other.

YOu might find this interesting.The House of God - Wikipedia, the free encyclopedia

[brainkandy87]

s/p = status post (I swear, it took me forever to learn this.. I'd always forget what it stood for)

ETOH = ETOH. Or, alcohol.

d/t = due to

r/t = related to

pt = patient

gtt = drip

[JBudd, MSN]

a&ox4 = alert and oriented to person, place, time and situation

NAD = no acute distress

CTA = clear to auscultaion

+BSx4 = bowel sounds present in all 4 quadrants

FROMx4 = full range of motion in all 4 extremities

MAE = moves all extremities

CR

BKA = below the knee amputation

AKA = above the knee amputation

IDDM = insulin dependent diabetes mellitus

NKDA = no known drug allergies

PERRLA = Pupils equal round, reactive to light and accomadating

RAMs intact = capable of rapid alternating movements (neuro)

[rncindyo]

CTA also means "catt scan angio" so be sure to check for correct usage of this one.

BS is used for Bowel sounds or Breath sounds,

due to the dual meanings of many abbreviations, it may be wisest to follow the first advice

and check for policy at your facility, seek out a list of their approved abbreviations

before using ones suggested here. Not all are universal anymore.

[psu_213, BSN, RN]

Definitely go with the abbreviation list for your facility. For instance at one facility for which I worked: Rt. was right...had to be capitalized and have the period. R/T was related to...capitalized with the slash. RT (again, capitalized) was respiratory therapy. Other places I've worked does not have the abbreviation for respiratory therapy.

Point is, abbreviations need to be precise and they can vary from place to place.

[knightlycomic]

laugh ........

So many terms some great some funny some ...........

FITH - F*!d in the head

F.U.B.A.R - F*^%#D up beyond all recognition

SLK - silly looking kid

DzS6P - Dozen short of a six pack

[hiddencatRN, BSN, RN]

We use FOS a lot, as in full of poop. Literally. This is our slang for constipation.