Triage and Assessment Abbreviation

[PMHNP2023, RN]

I am a new grad to the ED and have come across some abbreviations when reading ED Triage notes and ED Assessments specifically. I'd like people to add more to the list, to hopefully create a more comprehensive list of abbreviations, as I only know a few of them.

abx - antibiotics

bibm - brought in by medic

c/c - chief complaint

c/o - complaint of

perrl - pupils equal round reactive to light

pms - pulse, motor, sensory

sob - shortness of breath

s/p - status post

vss - vital signs stable

[Esme12, ASN, BSN, RN]

The problem with hospital specific abbreviation is that hey don't belonging on the record. The Joint Commission has a specific list of approved abbreviations that are the only ones you use. If your facility allows thee abbreviations they need to make them official. Using unofficial abbreviations can lead to misunderstandings and mistakes.

These abbreviations above are ok except bibm...it should be..... patient arrived via Town A per EMS/ALS. bibm is not an approved abbreviation.

[chare]

The problem with hospital specific abbreviation is that hey don't belonging on the record. The Joint Commission has a specific list of approved abbreviations that are the only ones you use. If your facility allows thee abbreviations they need to make them official. Using unofficial abbreviations can lead to misunderstandings and mistakes.

Can you provide a link for this list? All that I have been able to find is their list of prohibited abbreviations.

Thanks!

[psu_213, BSN, RN]

Also, I only use VSS when I take a call from a LTC facility/medic/etc. and they specifically report that vital signs are indeed stable. If I take the vital signs, then I chart the actual vitals signs, not just VSS.

I have never heard of "BIBM." Also, I have always seen CSM (circulation, sensation, movement), not PMS. Perhaps they are approved by your facility...otherwise, stick with approved abbreviations.

[zmansc, ASN, RN]

With our EMR we have a place for vitals which is where the specific numbers go. If I'm writing a note and explaining why I performed a treatment or dc'ed the O2 or something else I will use VSS or hypertensive, or whatever describes the situation without putting in specific numbers. I do this as a way to limit the double documentation that is unfortunately a part of our medical record. This way, if the reader wants the specifics they can look them up, but they know why we did something and the big picture from the note. It also keeps me from having a typo in the note that now confuses people as to what the vitals actually were.

As for the rest of the thread, I would agree that the abbreviations should be a short list of approved abbreviations and I would have no clue what BIBM meant.

[PMHNP2023, RN]

Our facility does have an approved list (14 pages long!) of abbreviations. However, some people use abbreviations outside of the approved list. I started this post to see some of these "non-standard" abbreviations, not so I could use them, but so that I can decipher some of these triage notes I get from the front when getting a new patient.

[Esme12, ASN, BSN, RN]

the best people to ask would be your fellow staff , your clinical educator, and your manager.

[1fastRN]

ROM=Range of motion

AAOx3/A&Ox3=Alert and oriented x3

CP= Chest Pain

HA= Head ache

AMS=Altered mental status

Abd= Abdomen

N&V= Nausea and vomiting

CA=Cancer

CVA=Stroke

Hx=History

COPD

LUQ,RUQ, etc= left upper quadrant, right, etc.

MVC=Motor vehicle crash

MI=Myocardial infarction

PO/IV

UTI=urinary tract infection

LOC=Loss of consciousness (also sometimes level of cons)

ETOH=Alcohol

ASA=Aspirin

NS=Normal Saline

BG/BS= Blood glucose/blood sugar

A lot of these I use when quoting medics/patients/family

I see a lot of people use NAD=No acute distress. But I feel like that may be too subjective?

But agreed, most facilities have a list of approved abbreviations or atleast the unexceptable ones. I try to avoid a lot of abbreviations besides the more common ones.

[Emergent, RN]

I've had our ER docs use abx in discharge instructions! LOL, I always explain to pts.

[JustBeachyNurse, LPN]

I was taught NAD = no apparent distress as this is how it appears on the list of approved abbreviations for my employers

[IrishErin]

We often use 'HBD' for 'has been drinking'.

[Bubbles]

ROM=Range of motion

AAOx3/A&Ox3=Alert and oriented x3

CP= Chest Pain

HA= Head ache

AMS=Altered mental status

Abd= Abdomen

N&V= Nausea and vomiting

CA=Cancer

CVA=Stroke

Hx=History

COPD

LUQ,RUQ, etc= left upper quadrant, right, etc.

MVC=Motor vehicle crash

MI=Myocardial infarction

PO/IV

UTI=urinary tract infection

LOC=Loss of consciousness (also sometimes level of cons)

ETOH=Alcohol

ASA=Aspirin

NS=Normal Saline

BG/BS= Blood glucose/blood sugar

A lot of these I use when quoting medics/patients/family

I see a lot of people use NAD=No acute distress. But I feel like that may be too subjective?

But agreed, most facilities have a list of approved abbreviations or atleast the unexceptable ones. I try to avoid a lot of abbreviations besides the more common ones.