Nursing preceptor says no to certain abbreviations

[cozzy66]

Hey all,

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:

S1S2 RRR

no CVA tenderness

CTA bilat

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.

Thanks.

[EricJRN, MSN, RN]

I can understand these, but at a certain point, it's going to be easier to go along with your preceptor temporarily than it is to argue. Once you're off of orientation, you can use your hospital's acceptable/unacceptable lists in order to chart how you like.

[Altra, BSN, RN]

I personally don't have any problems with the examples you have listed here. This is a question for your preceptor - "can you tell me why these are unacceptable? Is there a policy you can refer me to?"

You may find that this is one example of how practices vary from one individual to the next. Your preceptor's job, for right now, is to teach you his/her way. Don't sweat it, as long as you stick to abbreviations which are widely utilized by professionals in your specialty area and are not "do not use" abbreviations.

[Mrs. M.]

You need to get the list of approved abbreviations from your hospital. I have struggled with eliminating many of the old standard abbreviations from my routine, but I've had to change because it is a patient safety issue. Better to learn this correctly now than to have to re-learn later.

[mondkmondk]

I think the weirdest abbreviation I've ever come across was "CLWR" (call light within reach). During a deposition, I was informed by a nurse paralegal that this was not a defined abbreviation. Definitely learned to stick with more familiar ones/required ones after that.

Blessings, Michelle

[uscstu4lfe]

don't argue with your preceptor. just smile and go along with it. once you're off, you can do what you want.

[cozzy66]

Thanks for the responses! That's what I've been doing, but I am going to get that list so I know for the future...

[CHATSDALE]

there is or should be a list of acceptable abbrevations

preceptor has a point though..if you are called 5 years down the road and asked to read your notes in court it can be embarrassing if you stumble over what yu have written

[justme1972]

This isn't about if your perceptor is being reasonable or not...this is about picking your battles.

As a new employee, if your perceptor says you can't use the abbreviations...then don't use them. It doesn't really matter if she is going overboard or not, it's about you making a good impression as a team player and getting a good report back to management about you.

Physicians are not employees of the hospital...you are, that is even a bigger reason of why they can and you cannot.

PS: Abbreviations are not standard throughout the industry. If you go to medical websites that have abbreviations...you would be very surprised on how the SAME abbreviations, pull up several conditions, etc with the same initials.

[morte, LPN, LVN]

Hey all,

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:

S1S2 RRR

no CVA tenderness

CTA bilat

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.

Thanks.

actually it took me several minutes to figure out what CTA meant....can t say i have ever seen that one......and of course this is not the response you want to engender in whom ever is reading you note.....

[Straydandelion]

Having learned different abbreviations in school from what was used in the hospital I can understand fully the confusion, it appears different facillities have different abbreviations yet just because a doctor uses one doesn't mean that abbreviation is acceptable for that facillity. Agreeing with the rest, just "go with the flow" for now.

[Balder_LPN, LPN]

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.