Are abbreviations becoming obsolete?

[Carlos Danger]

Abbreviations are on the way out. JCAHO has banned many of the used-to-be common abbreviations, and many hospitals have simply adopted a "no abbreviations" policy.

It will trickle down to EMS before too long, I suspect.

 

[Clipper1]

JACHO is only following the recommendations and warnings issued by others such as the ISMP. This is nothing new since hospitals (with JACHO and other inspecting agencies for CMS) have started to change their abbreviation polices over 15 years ago. Some things such as medications should not be abbreviated. EMS sometimes takes liberty with this because they only deal with a few meds and do not know all of the variations of those few meds.

http://www.jointcommission.org/assets/1/18/SEA_23.pdf

 

[MarkusEMS]

OMG - pls keep those abbrev.!

I just last December finished my EMT training and I had to remember all those hundreds of pages of short versions of all those complicated words and conditions !!! ..seriously though... I'm sure that abbreviations and acronyms always will be around, as others pointed out Hx, Pt, B/P, Tx are the base of PCR (wops another one) writing and who doesn't prefer to write AAA Abdominal Aortic Aneurysm or some other condition that needs to be squeezed on the few lines when you actually still do handwritten reporting

TTYL
- Markus

 

[Bullets]

I just last December finished my EMT training and I had to remember all those hundreds of pages of short versions of all those complicated words and conditions !!! ..seriously though... I'm sure that abbreviations and acronyms always will be around, as others pointed out Hx, Pt, B/P, Tx are the base of PCR (wops another one) writing and who doesn't prefer to write AAA Abdominal Aortic Aneurysm or some other condition that needs to be squeezed on the few lines when you actually still do handwritten reporting

TTYL
- Markus

because if i saw a chart that said a patient was involved in a MVC and had AAA, i would not incorrectly think he had a annual subscritption to a roadside assistance company.

 

[WuLabsWuTecH]

I just last December finished my EMT training and I had to remember all those hundreds of pages of short versions of all those complicated words and conditions !!! ..seriously though... I'm sure that abbreviations and acronyms always will be around, as others pointed out Hx, Pt, B/P, Tx are the base of PCR (wops another one) writing and who doesn't prefer to write AAA Abdominal Aortic Aneurysm or some other condition that needs to be squeezed on the few lines when you actually still do handwritten reporting

TTYL
- Markus

Get a second sheet of paper? And while AAA is a bit of an anomaly because it's the same letter three times in a row, most abbreviations don't save that much time in my experience.

because if i saw a chart that said a patient was involved in a MVC and had AAA, i would not incorrectly think he had a annual subscritption to a roadside assistance company.

^^This. I would think the same thing and think it just indicated who else was on scene...

But context is also a huge part of it. If I heard a bruit at the sternal notch at the AAA, i'd know it was the ascending aortic arch. If I were auscultating in the epigastic area, I'd know it's an Abdominal Aortic Aneurysm (because there is no ascending aortic arch at that level...). If I were selling bonds, I'd know it was a rating. If I was repairing a flat, I'd know it's a car club.

 

[Rialaigh]

because if i saw a chart that said a patient was involved in a MVC and had AAA, i would not incorrectly think he had a annual subscritption to a roadside assistance company.

The problem is when the jury your standing in front of is trying to get an explanation of what AAA is and their first thought is a roadside assistance company. The opposing lawyer will absolutely tear you apart on "what ifs" and the like. It's a cover your butt tool. The more complete you are (and this includes not using abbreviations) the less likely you will be found liable of something in a court of law.


Now in the hospital (as an ER tech) I use abbreviations all the time because nothing I write and hand to people gets placed in a patients chart. If I hand the nurse or doc a piece of paper that says HR, BP, and RR, with other vitals on it they know what that is...that paper does not get scanned into a patients chart or anything, it is for nursing reference.

 

[TheLocalMedic]

One of the hospitals we deliver to require a brief handwritten report on the pt condition and treatments. However, most of the page is taken up by check boxes (Seizure? YES NO Pregnant? YES NO) and they only leave you four lines at the bottom of the page for narrative, so pretty much everything I write up is abbreviated...

"34 YOM c/o CP w/ SOB x2 days. Pt states neg Hx or home Rx..."

It annoys me to have to abbreviate everything, and looking over other peoples' notes made me realize that what we're writing is nearly indecipherable. Not a fan of abbreviations.

 

[DrParasite]

The problem is when the jury your standing in front of is trying to get an explanation of what AAA is and their first thought is a roadside assistance company. The opposing lawyer will absolutely tear you apart on "what ifs" and the like. It's a cover your butt tool. The more complete you are (and this includes not using abbreviations) the less likely you will be found liable of something in a court of law.

please cite one case where that actually happened. Bet you won't find one. It's fear mongering, the attorney will tear you to shreds, blah blah blah.

How about this: I get on the stand and said pt didn't have AAA, and let the attorney ask me what it means. Abdominal Aortic Aneurysm. Attorney: Are you sure you don't mean roadside assistance? DrP: pretty sure, because it was noted when I examined his abdomen. If my documentation gets called into question, it falls upon me to explain it; not my coworker, not my supervisor, not the receiving hospital, not the garbage man, not the guy who cleans the floors, it falls on the author of the document. If you don't know, than you should ask.

Now in the hospital (as an ER tech) I use abbreviations all the time because nothing I write and hand to people gets placed in a patients chart. If I hand the nurse or doc a piece of paper that says HR, BP, and RR, with other vitals on it they know what that is...that paper does not get scanned into a patients chart or anything, it is for nursing reference.

Which is an even bigger potential for liability, because 1) they don't know if you were right or not 2) they are treating based on those vitals 3) if they are wrong, there is no proof anywhere of what you told the nurse was, when compared to what's in the chart, and if you have a "senior moment" and misread a BP of 180/60 when it's actually 80/60, and the patient is treated based on wrong information, than it falls on the nurse who entered that information in, not the tech who scribbled it on a piece of scrap paper.

"34 YOM c/o CP w/ SOB x2 days. Pt states neg Hx or home Rx..."

I can translate that very clearly actually.....

As was mentioned before, JACHO recommends not using abbreviations, except for "approved" ones. We have a list somewhere. Like many on here, I started with abbreviations on paper charts, and since we went electronic, they carried over. I know many places are trying to get away from them, but I don't see it happening any time soon.

 

[DesertMedic66]

The problem is when the jury your standing in front of is trying to get an explanation of what AAA is and their first thought is a roadside assistance company. The opposing lawyer will absolutely tear you apart on "what ifs" and the like. It's a cover your butt tool. The more complete you are (and this includes not using abbreviations) the less likely you will be found liable of something in a court of law.


Now in the hospital (as an ER tech) I use abbreviations all the time because nothing I write and hand to people gets placed in a patients chart. If I hand the nurse or doc a piece of paper that says HR, BP, and RR, with other vitals on it they know what that is...that paper does not get scanned into a patients chart or anything, it is for nursing reference.

Patient has a medical history of an AAA. I can easily see how it could be translated into "Patient has a medical history of being an insured driver through the Auto Club"

 

[JPINFV]

I'm still trying to figure out why polymerase chain reactions are so popular in EMS.

 

[DesertMedic66]

I'm still trying to figure out why polymerase chain reactions are so popular in EMS.

 

[chaz90]

I'm still trying to figure out why polymerase chain reactions are so popular in EMS.

And how we've discovered a novel way to use it to document pt. records. Sounds like a Nobel prize for someone...