Patient A+0x3, ST with PVCs and PACs. Lungs clear bilaterally with POX 98% on RA and SOB on exertion, PPP, NPO after midnight. PERRLA. Normal BSx4 quadrants. Abd dressing C/D/I C scant amt of serosang drainage. MAE, SBA, and OOB as tolerated. BP WNL. NS infusing @75 ml/hr through RTL PICC, F/P.
Reading medical charts can be confusing to those not familiar with medical terminology and abbreviations. The paragraph above can be frustrating for a new monitor who already had to learn research terminology but now they have to develop their medical terminology skillset. Let’s take a look at a few common abbreviations below:
|RA – room air, or rheumatoid arthritis, depending on context||D/C – discontinue or discharge||NC – nasal cannula|
|R/O – rule out||S – without||PPP – pedal pulses palpable|
|PO – by mouth||C – with||OOB – out of bed|
|SOB – shortness of breath||P – after||CPAP – continuous positive airway pressure|
|RVR – rapid ventricular rate||PERRLA – pupils equal, round, and reactive to light accommodation||BiPAP – bilevel positive airway pressure|
|C/O – complains of||WNL – within normal limit|
Now that we have gone through a few of them let’s revisit that paragraph from above. Patient is alert and oriented times three. Sinus tachycardia with premature ventricular contractions and premature atrial contractions. Lungs are clear bilaterally with pulse oximetry 98% on room air and shortness of breath on exertion. Pedal pulses are palpable. Nothing by mouth after midnight. Pupils equal, round, and reactive to light accommodation. Normal bowel sounds times four quadrants. Abdominal dressing is clean, dry, and intact with scant amount of serosangious drainage. Moves all extremities, stand-by assist, and out-of-bed as tolerated. Blood pressure within normal limits. Normal saline infusing at 75 milliliters per hour through a right triple lumen peripherally inserted central catheter, flushes and patent.
After reading that paragraph, I think we can all agree that abbreviations can not only help cut down some of the charting but allow those in the research and medical field to read notes fluently. This is just a small sample size but a more comprehensive list can be found here. Good monitors understand the importance of reading medical charts and that potential adverse events can be hidden in medical abbreviations.
How many of you have discovered adverse events in abbreviations? Take this practice quiz.photo credit: mikecogh The Gr8 Db8 via photopin (license)