Patient Note abbreviations

[Jamaicacarioca]

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Hey guys, Just read and tell me if any of the abbreviations are not acceptable.Please try and help out🙂 Please give me the abbreviations for the peripheral pulses.

PE:
GA: nad
VS: wnl
HEENT: AT/NC, fundi wnl,EOMI,PERRLA,TM intact,oropharynx wnl
Neck: Thyroid wnl, -JVD,- carotid bruits,-LAD
Chest: CTA B/L
Heart: RRR,S1/S2 wnl, no RMG
Abd: s/nt/nd, +BS,no masses

 

[OveractiveBrain]

Hey guys, Just read and tell me if any of the abbreviations are not acceptable.Please try and help out🙂 Please give me the abbreviations for the peripheral pulses.

PE:
GA: nad
VS: wnl
HEENT: AT/NC, fundi wnl,EOMI,PERRLA,TM intact,oropharynx wnl
Neck: Thyroid wnl, -JVD,- carotid bruits,-LAD
Chest: CTA B/L
Heart: RRR,S1/S2 wnl, no RMG
Abd: s/nt/nd, +BS,no masses

Standpoint 1: Medical Legal

"Abbreviations are not to be used on patient notes" - official response

"As long as people understand what you're saying" - unofficial response

I dont know what AT/NC means (therefore you are violating both rules)

All the other ones I can understand. So, I guess you are only in violation of the first one. If someone comes to this thread and has to ask, "what does - LAD mean?" How do they live with a Left Anterior Descending Artery, and how can you tell!? Then you aren't doing what you're supposed to.

Standpoint 2: Logic
I personally like "code" in my handwritten notes. What it conveys is "i did the exam and its normal, even if you can't interpret what I've said, you can at least feel that its not important that you can interpret it, so its normal." Also, when you read my note and there is something spelled out, with full words, it catches your eye. All that other stuff is jibber jabber I don't understand, but THIS ahhhhh, this description stands out and is useful for what is NOT NORMAL!

Take it as you will.

 

[Raryn]

Standpoint 1: Medical Legal

"Abbreviations are not to be used on patient notes" - official response

"As long as people understand what you're saying" - unofficial response

I dont know what AT/NC means (therefore you are violating both rules)

All the other ones I can understand. So, I guess you are only in violation of the first one. If someone comes to this thread and has to ask, "what does - LAD mean?" How do they live with a Left Anterior Descending Artery, and how can you tell!? Then you aren't doing what you're supposed to.

Standpoint 2: Logic
I personally like "code" in my handwritten notes. What it conveys is "i did the exam and its normal, even if you can't interpret what I've said, you can at least feel that its not important that you can interpret it, so its normal." Also, when you read my note and there is something spelled out, with full words, it catches your eye. All that other stuff is jibber jabber I don't understand, but THIS ahhhhh, this description stands out and is useful for what is NOT NORMAL!

Take it as you will.

http://www.usmle.org/pdfs/step-2-cs/content_step2cs.pdf page 14 has a list of examples of appropriate abbreviations, and has the admonition "There is no need to use abbreviations on the patient note; if you are in doubt about the correct abbreviation, write it out." All of the OP's stuff is pretty understandable to anyone who has been in medical school (AT/NC I've usually seen written as NCAT. Normocephalic, Atraumatic), and the people grading notes are physicians, but I'd probably err on the side of writing more if you can type at an appropriate speed.