Report writing.

[coloradoemt]

I spent the first year and a half in EMS running in a system that had computers on which we filled out trip reports. Now I have to do it the paper way. I would like to see some accepted abbreviations to keep my hand from cramping up!! :lol: I realize all of you probably have differing ideas, but then I could pick and choose.

 

[MedicPrincess]

Here is a decent list.


Abbriviations

 

[rescuecpt]

I have always been told (and have seen this posted in hospitals) not to use abbreviations if possible, since there isn't really a universal method. I know it applies more to doctors and nurses, since dosing problems have occurred due to confusion of abbreviations.

Although I do use things like HEENT, PERRL, (-), (+), and (=)

 

[coloradoemt]

Thankyou Princess.

 

[coloradoemt]

Originally posted by rescuecpt@Jan 10 2005, 09:20 AM
I have always been told (and have seen this posted in hospitals) not to use abbreviations if possible, since there isn't really a universal method.

This is the reason I thought I would start this topic. I got to thinking that there are so many ways to abbreviate things it would not be worth abbreviating anything in the long run.

 

[SafetyPro2]

These are the ones we generally use, in no particular order (just wrote them as I thought of them). Most of these are self-explanatory, but I'll give the definitions anyway. Some of these are used by our dispatch for the detail text too.

PT - patient
male and female symbols for gender (I really hate this as I never remember them, so I usually spell it out)
A&O - alert and oriented
MI - myocardial infarction
CVA - cardiovascular attack (aka stroke)
EtOH - alcohol
5150 - suicidal or otherwise threat to self/others
PERL - pupils equal and reactive to light
diff - difficulty (as in "diff breathing")
x - modifier for length of time ("x 3 days" would be symptoms for past 3 days)
GCS - Glasgow Coma Scale (which in our system is really the LA County Modified Glasgow Coma Scale)
abd - abdominal
GIB - gastrointestinal bleed
ALOC - altered level of consciousness
HX - history
c-spine - cervical spinal precautions
KO - loss of consciousness
NKA - no known allergies
FX - fracture
poss - possible (as in "poss FX")
OD - overdose
BP - blood pressure

 

[PArescueEMT]

The medication abbrev. thing has to do moreso with something like:

MSO4 (morphine sulfate) can be confused with MGSO4 (mag sulfate)

that is one of the reasons that hospitals avoid using them.

 

[DFDEMS]

You will end up writing a novel if you don’t use abbreviations at some point. The trick is to figure out what works for you.

Abbreviating meds is a bad idea as PArescueEMT pointed out.

 

[SafetyPro2]

Originally posted by DFDEMS@Jan 13 2005, 10:28 PM
Abbreviating meds is a bad idea as PArescueEMT pointed out.

Hesk, half the time I don't even know how to spell it, let alone abbreviate it. I try to stay up on the common ones at least, but every so often there's a good head-scratcher...particularly if the patient isn't at home and we don't have ready access to the actual bottles.

Of course, I always love it when the patient doesn't even know the meds he/she takes.

 

[PArescueEMT]

I love it when I have a Pt. that speaks only russian. Try to figure out what they are saying... let alone their meds.

This happens more than I would like. Once a week at least.

 

[rescuecpt]

Originally posted by PArescueEMT@Jan 14 2005, 02:24 AM
I love it when I have a Pt. that speaks only russian. Try to figure out what they are saying... let alone their meds.

This happens more than I would like. Once a week at least.

I had one of those! It was very frustrating because she seemed like a nice little old lady and she was all alone. I just kept using basic words and spoke in a soft tone... by the time we got to the hospital she was holding my hand and kissing it. Guess that means she liked me.

 

[Chimpie]

Not to get off course, but this is just too funny not to tell.

I used to work at the Toyota plant in Indiana. We had an "ER" type center there at the plant. Two trama rooms, trama shower, 5 regular examination room, and every drug and piece of machinery you can think of. The only thing we didn't have was an x-ray.

Anyway, we were super safe when we did any kind of transport. We did the usual backboard and c-collar, cross tape, blah blah. We were usually on a first name basis with most of the workers so we joked around with them a lot. Quite often as we're getting vitals we would write the info down on the tape that ran across their forehead. No matter how much they were in pain it was funny as hell when they look straight up at you and you know they're thinking: Is he writing something on my head? LOL To give the docs a laugh we often used the abbreviation FDGB.

Fall down, go boom

After a while we were told not to do that anymore. Okay, so we did it depending on the doc on duty at the time.

Gosh I miss the good ol' days.

Chimp

 

[Jon]

Originally posted by rescuecpt+Jan 14 2005, 09:45 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>QUOTE (rescuecpt @ Jan 14 2005, 09:45 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-PArescueEMT@Jan 14 2005, 02:24 AM
I love it when I have a Pt. that speaks only russian. Try to figure out what they are saying... let alone their meds.

This happens more than I would like. Once a week at least.

I had one of those! It was very frustrating because she seemed like a nice little old lady and she was all alone. I just kept using basic words and spoke in a soft tone... by the time we got to the hospital she was holding my hand and kissing it. Guess that means she liked me. [/b][/quote]
his advantage is that he usually has a partner who understands russian. Might not understand any more english than the patient, but....


Oh, and abbrivations are kosher as long as EVERYONE you deal with understands the abbreviation, thats why in PA every Co. must have an "approved" abbriviation list....I mean, look - we all use ED and ER, right?????


Jon

 

[PArescueEMT]

It was fun yesterday... Russian Emergency... Seizures... 911 called as well as the private company I work for. We get on scene less than 1 minute AFTER 911 and they had half the distance as a head start. Any who... we get there and find that there is nobody on scene who cantranslate for PD, FD, Family, Nighbors (who called both of us in the first place), etc.
My partner is a Refugee from the Ukraine and speaks broken English AND Russian (better russian than english). I start feeding him the questions to be answered for 911, and translated to me... who re-translated for PD and FD.


Long story short:
Diabetic, No PO intake x2 days, Drank half a bottle of vodka 2.5 days ago.

Fun, Fun, Fun

 

[coloradoemt]

Well thanks to all of you and the suggestions you have. As I have found out recently it is not my abbreviations so much as my hand writing I need to improve on... h34r:

 

[PArescueEMT]

I know that feeling. I had a boss that told me "I have to admit, you got into the right field. So your choices are this state form or that computer." I ended up driving after that.

 

[Jon]

Originally posted by coloradoemt@Jan 15 2005, 10:06 PM
Well thanks to all of you and the suggestions you have. As I have found out recently it is not my abbreviations so much as my hand writing I need to improve on... h34r:

ask whackerDude (RescueEMT's other name) about my chicken scratch. I could probably be a doctor!

 

[coloradoemt]

I spent 7 years as a helicopter mechanic in the Army... After writing maintenance procedures all day and signing my name 50-60 times a day my hand writing leaves alot to be desired. My reports are getting better though.

 

[SafetyPro2]

We just had a great drill on patient assessment and documentation last week by our EMS Coordinator. Apparently, there is a county standard list of med abbreviations that the medics use. Our EMS BC is putting together a cheat-sheet for the traume box clipboard. I'll see if I can get a copy and post it here.

 

[Phridae]

We're going to the computer reports probably within this year.
We're allowed to use abbreviations, just not with meds. They have to be spelled out so theres no confustion.