Lvillemedic
Forum Ride Along
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Pertinent Negatives..Don't forget these!!!!
Something I always add is the pertinent negatives..i.e. Pt c/c of rapid heart rate, but pulse normal and NSR on monitor, or showing STEMI with out physical signs or symptoms also known as a silent MI..
As for abbreviations: Do not use ETOH unless you can fully state what ETOH is..besides alcohol intoxication... an attorney will eat you alive in court. I alway use "smells of alcoholic beverage" because alcohol by it's self has no smell or color....I also like the little triangle that stands for changes and is well known in the hospitals......Atleast around here....
Something I always add is the pertinent negatives..i.e. Pt c/c of rapid heart rate, but pulse normal and NSR on monitor, or showing STEMI with out physical signs or symptoms also known as a silent MI..
As for abbreviations: Do not use ETOH unless you can fully state what ETOH is..besides alcohol intoxication... an attorney will eat you alive in court. I alway use "smells of alcoholic beverage" because alcohol by it's self has no smell or color....I also like the little triangle that stands for changes and is well known in the hospitals......Atleast around here....