Q on writing notes in CS

[rxfudd]

Did you guys include the vitals in your note? FA just writes "VS: WNL" in their examples - is this acceptable?

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[tigershark]

only if it's relevant

 

[inositide]

for the CS exam, vitals should only be written the physical exam if they are directy relevant to the illness. if the pt has knee pain, and all his vitals are normal, there is no need to recopy the vitals.

 

[fukuisan]

When writing our patient notes, is it ok to abbreviate everything? Like n/v for nausea and vomiting, f/c for fever and chills? First Aid uses many abbreviations for the PE like RLQ tenderness and +BS but writes everything out in the history.

Thanks for the help.

 

[orientedtoself]

When writing our patient notes, is it ok to abbreviate everything? Like n/v for nausea and vomiting, f/c for fever and chills? First Aid uses many abbreviations for the PE like RLQ tenderness and +BS but writes everything out in the history.

Thanks for the help.

Yes, you are allowed to use commonly accepted abbreviations in the note.