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.

[not now, RN]

I hate reading charts and not knowing what the writer is saying because it's messy or full of abbreviations that I don't understand. For that reason alone I don't abbreviate in my charting. Ever. When I worked in LTC I wrote everything out. Now I'm in critical care and we are the only department that doesn't chart on the computer. I still write everything out. I also write in large clear letters so no one (not even me) has any doubt what I'm describing.

Find out what is approved at your facility and go by that.

[Dolce, RN]

I hate reading charts and not knowing what the writer is saying because it's messy or full of abbreviations that I don't understand. For that reason alone I don't abbreviate in my charting. Ever. When I worked in LTC I wrote everything out. Now I'm in critical care and we are the only department that doesn't chart on the computer. I still write everything out. I also write in large clear letters so no one (not even me) has any doubt what I'm describing.

Find out what is approved at your facility and go by that.

Thank you!!!! I love nurses like you!

[GrumpyRN63, ADN, RN]

I'm not sure what CVA tenderness is? It took me a minute to figure out CTA--I've seen it written LCTA, not just CTA. The main thing is that most hospitals are getting away from abbreviations. Probably in the future we aren't going to be using them at all. There is just way too much room for error. Especially with some nurses who I have worked with that have their own "made up" abbreviations. Stick to the most common ones and you should be fine. :)

Positive CVA tenderness when assessing back vs. flank pain -usually indicative of pyelo

[Dolce, RN]

Positive CVA tenderness when assessing back vs. flank pain -usually indicative of pyelo

Okay, thanks. I get it now.

[blondy2061h, MSN, RN]

I'm not sure what CVA tenderness is? It took me a minute to figure out CTA--I've seen it written LCTA, not just CTA. The main thing is that most hospitals are getting away from abbreviations. Probably in the future we aren't going to be using them at all. There is just way too much room for error. Especially with some nurses who I have worked with that have their own "made up" abbreviations. Stick to the most common ones and you should be fine. :)

Costovertebral angle tenderness. It's pain on the side/back over the kidneys.

[morte, LPN, LVN]

Thanks. I had no clue what that meant. It still doesn't make a whole lot of sense in the context of "tenderness." Why would we need to chart no CVA tenderness?

as the previous poster said, it relates to kidney issues....

[cherrybreeze, ADN, RN]

I've only seen the "CVA tenderness" reference in MD dictation, not in nurses' notes. I wasn't technically taught how to assess it (not that it's hard, but was never actually shown the technique, if that makes sense).

Notes are DEFINITELY part of the medical record; I was called to testify in a case where the med record came in to play (not about a patient care issue, though, it was a domestic one) and I HAD to refer back to my notes to refresh my memory of the events of that particular shift. Thank goodness I could!