<img height="1" width="1" style="display:none" src="https://www.facebook.com/tr?id=213807269037206&amp;ev=PageView&amp;noscript=1">
blog-hero.jpg
Compliance In Focus
Posted by Ashton Steinhagen on Tue, May 23, 2017

Medical Abbreviations: A Language WNL

Patient A+0x3, ST with PVCs and PACs. Lungs clear bilaterally with POX 98% on RA and SOBMedical Abbreviations II.jpg 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)

Topics: Medical Abbreviations, Research Terminology

imarc

Posts by Topic:

All