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.
Anytime someone has to use Google to read your charting, you probably are not using standard abbreviations.
The last time I actually saw BIBM used in an acute medical setting was in the 80s to identify high risks for HIV. Medic is also a shortened term in the civilian world for Paramedic.
Your hospital should have and approved list of abbreviations and the national DO NOT use list since this is on the JACHO surveys.
A&Ox4: alert and oriented to person, place, time, and situation
Tx: treatment
AAA: abdominal aortic aneurysm
HI5: HIV +
... this is a list of things commonly used/seen. I'm not saying they SHOULD be used. In order to properly communicate, all words should be spelled out.
... this is a list of things commonly used/seen. I'm not saying they SHOULD be used. In order to properly communicate, all words should be spelled out.
Not so much directing this at you, but at people who use the "abbreviation"...why would you put the slang for HIV in the chart? It is an official record, it's not for everyone to read, and typing HI5 saves you a whole one keystroke as compared with HIV+. If others (i.e. those not involved with the pt's care) are around, I would not use the slang since they might know what it means...to actually chart it really makes no sense either.
Those are about the only abbreviations I use on a regular basis, and I'm pretty consistent about it. That is my understanding, is that if you are consistent about the way you chart, then even if it's years later and you're asked to review something you charted, you will be able to explain exactly what was going on with the patient because you are consistent in the way you document.
Bubbles
158 Posts
This system is not working properly. My apologies to the person who did enter the post.