Abbreviation question

[JuliaD]

I am a medical transcriptionist summarizing medical records for a physician. I have an EMT report which indicates patient status after an MVA "
PT A&OX3 VITALS WNL +AIRBAG +SEATBELT. PT STATED THAT SHE 10/10 PAIN
-HAM
+SEATBELT +AIR BAG" I understand all except -HAM - can anyone tell me what that references? Something about head or air movement ??

 

[DesertMedic66]

History, Allergies, Medications?

Any abbreviations that are being used during charting should be pre approved by the company to avoid this issue.

 

[JuliaD]

Thank you so much. I will add this to my abbreviation list for future reference. I am summarizing records from many different facilities, so I don't have company chart standards as part of my reference material I appreciate your assistance.

 

[CCCSD]

Hint: WNL means no vitals were taken. If pt C/O pain at 10/10, there is NO way vitals were “WNL”.

WNL = We never look. We never listen.

 

[PotatoMedic]

I wish I could get away with my reports being that lax.

 

[CCCSD]

I wish I could get away with my reports being that lax.

Wait till it goes to court…

 

[E tank]

ha...verbal reports are 'no meds, allergies or history'...never thought about writing that buzz phrase down but switching up the order to -
HAM is easier...new one on me tho...

 

[DrParasite]

Wait till it goes to court…

you know, I've heard that urban legend... that if I used an "unapproved" urban legend it would look horrible in court...

no one has been able to provide me with a single documented case of an unapproved abbreviation resulting in a court decision going against a provider.

I've never used -HAM, nor do I know what it means, but it's very likely that if you put the EMT who wrote that on a witness stand, they would know what that means.

I have been writing charts for the better part of 20 years, and not all of my abbreviations were on the "approved list." And while it might cause my QA person a little heartburn and headache, if you asked me what it means, I would be able to expand on it. and if you put me in court, I would defend the factual accounting of my narrative, coupled with the rest of the information on the PCR. You can try to get me to change it (and many have tried), but 20 years later, I want my charting to be consistent, so if I'm pulled into court, I can say, with 100% certainty what I meant, and my entire documenting history reflects my use of that particular abbreviation.

WNL = We never look. We never listen.

No, it doesn't, and you know that as well as I do. it stands for within normal limits, which likely would correlate to the numerical values for each vital sign that is noted elsewhere on the PCR. As long as it's documented somewhere, there is no need to duplicate information, since duplicating information increases the chances of conflicting information on a PCR, which even a poor lawyer would pick up on in court, and destroy the provider's credibility on a witness stand.

We really need to stop spreading these unfounded EMS urban legends when it comes to documentation.

 

[johnrsemt]

Here is the problem of WNL or within normal limits: Unless you transport or treat that patient everyday and at the same time everyday, you have no idea what their normal is. I was part of a study 30 years ago and my VS were taken every hour 5 days a week for a 6 month period at a doctors office next to my store.
I varied about 10 points on BP and HR consistently throughout the day up and down.

Also in December of 2019 I was in the Local ED, in extreme pain due to being attacked by a corral gate, that was kicked by a 1,500 lb bull Buffalo. 8/10 pain. BP 135/102, HR 110. ED Doc (resident) was nice and ordered 100mcg Fentanyl which the ED nurse chased me to CT and gave me just before it started. When I was back in the ED room 8 minutes later my VS were "within normal limits": 80/40 HR 64.
Doctor and 3 nurses were freaked out. I got them to listen to me by yelling "Go talk to the 'real' doctor, and check my chart; I am not crashing, I am fine".
That is seriously my normal BP. I was not in pain any longer, and a little high, because I know better than to tell a Resident to go talk to a 'Real Doctor', usually doesn't end well.
She and the Attending came back and looked up my chart in the computer and were shocked that I was right. That was my normal BP.

So back to the beginning: What is "Within Normal Limits"? Whose Normal? What is Normal" 80/40 is normal for me, 135/100 is normal for my partner. But if you don't know either of us, even if you transport us for the 45-90 minutes that we transport to the close hospitals can you really put that down in a report? Because even if it is consistent during the transport, is it 'normal' for that patient?
My dad is 91 years old next month, and his resting HR is 48. Is that normal for a 90 year old male? It is for him, but no it is not normal.

 

[E tank]

Here is the problem of WNL or within normal limits: Unless you transport or treat that patient everyday and at the same time everyday, you have no idea what their normal is. I was part of a study 30 years ago and my VS were taken every hour 5 days a week for a 6 month period at a doctors office next to my store.
I varied about 10 points on BP and HR consistently throughout the day up and down.

Also in December of 2019 I was in the Local ED, in extreme pain due to being attacked by a corral gate, that was kicked by a 1,500 lb bull Buffalo. 8/10 pain. BP 135/102, HR 110. ED Doc (resident) was nice and ordered 100mcg Fentanyl which the ED nurse chased me to CT and gave me just before it started. When I was back in the ED room 8 minutes later my VS were "within normal limits": 80/40 HR 64.
Doctor and 3 nurses were freaked out. I got them to listen to me by yelling "Go talk to the 'real' doctor, and check my chart; I am not crashing, I am fine".
That is seriously my normal BP. I was not in pain any longer, and a little high, because I know better than to tell a Resident to go talk to a 'Real Doctor', usually doesn't end well.
She and the Attending came back and looked up my chart in the computer and were shocked that I was right. That was my normal BP.

So back to the beginning: What is "Within Normal Limits"? Whose Normal? What is Normal" 80/40 is normal for me, 135/100 is normal for my partner. But if you don't know either of us, even if you transport us for the 45-90 minutes that we transport to the close hospitals can you really put that down in a report? Because even if it is consistent during the transport, is it 'normal' for that patient?
My dad is 91 years old next month, and his resting HR is 48. Is that normal for a 90 year old male? It is for him, but no it is not normal.

Your partner needs to be on an anti-hypertensive med.

 

[CCCSD]

you know, I've heard that urban legend... that if I used an "unapproved" urban legend it would look horrible in court...

no one has been able to provide me with a single documented case of an unapproved abbreviation resulting in a court decision going against a provider.

I've never used -HAM, nor do I know what it means, but it's very likely that if you put the EMT who wrote that on a witness stand, they would know what that means.

I have been writing charts for the better part of 20 years, and not all of my abbreviations were on the "approved list." And while it might cause my QA person a little heartburn and headache, if you asked me what it means, I would be able to expand on it. and if you put me in court, I would defend the factual accounting of my narrative, coupled with the rest of the information on the PCR. You can try to get me to change it (and many have tried), but 20 years later, I want my charting to be consistent, so if I'm pulled into court, I can say, with 100% certainty what I meant, and my entire documenting history reflects my use of that particular abbreviation.

No, it doesn't, and you know that as well as I do. it stands for within normal limits, which likely would correlate to the numerical values for each vital sign that is noted elsewhere on the PCR. As long as it's documented somewhere, there is no need to duplicate information, since duplicating information increases the chances of conflicting information on a PCR, which even a poor lawyer would pick up on in court, and destroy the provider's credibility on a witness stand.

We really need to stop spreading these unfounded EMS urban legends when it comes to documentation.

I’ve been in court. Testified. Later been a Bailiff in civil trials. There’s a rule in court trials: didn’t write it, didn’t do it.

Guess you don’t know as much as you think about everything EMS. Stop pontificating.

 

[akflightmedic]

One of the things I love about nursing. Everything is WNL unless stated otherwise. My charting consists of ticking boxes that say a review of each system was completed and was WNL.

I echo Dr. Parasite about perpetuating the EMS urban legends and lack of supporting evidence to such claims of being in court, blah blah blah.

I do find it weird that a doctor and three nurses would “freak out” in an ER setting upon seeing a BP of 80/40 of someone who just received narcs yet is mostly alert and asymptomatic otherwise. In my experience, it would be one nurse who would say “oh, little drop in the BP, let’s give a small fluid bonus” followed by informing the provider. Even getting a second doc involved…

Anyways, WNL is quite acceptable and rather well established in the medical charting world thankfully.

*28 years now. Been to court twice for EMS calls which were of a civil nature not directly involving my care/charting (more as medical witness to the injured parties claim), and deposed once for a claim made against me, partner, county EMS service. None had issue with abbreviations or WNL. The one claim against me went nowhere and that was a call I did not even take a BP on. I have written about it here in past years.

 

[CCCSD]

So my episode of bradycardia was WNL. Ok. You do you.

 

[akflightmedic]

So my episode of bradycardia was WNL. Ok. You do you.

I don’t see anywhere you posted about being Brady, unless you are Johns 90 year old dad.

Having said that, you actually prove the point. Your HR would be documented as rate of 48, asymptomatic, pt states this is their normal. Job done.

You seem to maybe want to make a point that because you are a statistical outlier to the WNL parameters widely accepted in the medical field, that this is somehow far more complicated than what it is. All you do is write the objective (rate of 48), along with all other systems WNL and then capture the patient quote of “this is my normal”.

 

[DrParasite]

I’ve been in court. Testified. Later been a Bailiff in civil trials. There’s a rule in court trials: didn’t write it, didn’t do it.

do you have any idea what you are talking about, or do you like bringing up irrelevant facts about your past? I never said don't take vitals, nor did I say don't document vitals. In case you have forgotten what I said here it is (with some additional bold and underlying to make sure you don't miss the important parts):

No, it doesn't, and you know that as well as I do. it stands for within normal limits, which likely would correlate to the numerical values for each vital sign that is noted elsewhere on the PCR. As long as it's documented somewhere, there is no need to duplicate information, since duplicating information increases the chances of conflicting information on a PCR, which even a poor lawyer would pick up on in court, and destroy the provider's credibility on a witness stand.

See, even following the rule you state in the trial court, "didn’t write it, didn’t do it" except nowhere did I say not to document vitals, only that if they were within normal limits, you can put WNL, provided they are appropriate for the patient's condition and documented elsewhere on the chart.

Guess you don’t know as much as you think about everything EMS. Stop pontificating.

I don't know everything about EMS, but based on your previous pontificating, I clearly know more than you. At least we all know my reading comprehension skills are better then yours.

 

[CCCSD]

do you have any idea what you are talking about, or do you like bringing up irrelevant facts about your past? I never said don't take vitals, nor did I say don't document vitals. In case you have forgotten what I said here it is (with some additional bold and underlying to make sure you don't miss the important parts):

See, even following the rule you state in the trial court, "didn’t write it, didn’t do it" except nowhere did I say not to document vitals, only that if they were within normal limits, you can put WNL, provided they are appropriate for the patient's condition and documented elsewhere on the chart.

I don't know everything about EMS, but based on your previous pontificating, I clearly know more than you. At least we all know my reading comprehension skills are better then yours.

Dude, just grow up. You’re out of your depth.

 

[CCCSD]

I don’t see anywhere you posted about being Brady, unless you are Johns 90 year old dad.

Having said that, you actually prove the point. Your HR would be documented as rate of 48, asymptomatic, pt states this is their normal. Job done.

You seem to maybe want to make a point that because you are a statistical outlier to the WNL parameters widely accepted in the medical field, that this is somehow far more complicated than what it is. All you do is write the objective (rate of 48), along with all other systems WNL and then capture the patient quote of “this is my normal”.

Funny that WNL as I posted was taught to me by a very experienced CCRN with years of experience in EMS, nursing, HEMS/HAA, ICU/CCU. But I guess you all know better than she or the attorneys.

The Brady makes my point. You would document it as “WNL”, when it’s not, as I don’t have bradycardia.

 

[Jim37F]

I will say I've given verbal reports saying negative Ham and vitals were within normal limits.
But actual documentation on the ePCR would specify the History, Allergies, Meds, and actual Vitals numbers.

I don't think I've ever written "-HAM" and/or "Vitals WNL" but if so, that'd have been in the narrative paragraph section. Meanwhile all the PCRs (paper and electronic) I've dealt with had dedicated spaces to write in the actual History/Allergies/Medications/Vitals, so even if written in the Narrative that way, the more detailed specifics are still documented on the form.

 

[silver]

Funny that WNL as I posted was taught to me by a very experienced CCRN with years of experience in EMS, nursing, HEMS/HAA, ICU/CCU. But I guess you all know better than she or the attorneys.

The Brady makes my point. You would document it as “WNL”, when it’s not, as I don’t have bradycardia.

I find that people may write WNL when they mean unremarkable.

 

[Aprz]

When I used to get EMT student ride alongs, I used to go over acronyms and mnemonics with them. I'd tell them not everyone uses the same acronyms. I'd also tell them you could ask more or less than what's in the acronym. I'd also teach them that you can ask more things per letter rather than just asking one things. So examples would be DCAPBTLS vs DCAPBLSTIC. When it came to SAMPLE, I told them I didn't like L for last oral intake and that I almost never asked it. I'd only ask it if it was the hypoglycemic call, then I was curious when they last ate and not really what. Sometimes it'd matter if it related to their complaint like they started having abdominal pain or nausea after eating. Otherwise I never really asked it. So I'd tell them about HAM as an alternative for History, Allergies, and Medications. Then I made-up SHAME, Signs and symptoms, History, Allergies, Medications, and Events leading up to. I'd tell the students joking "SHAME the patient for me". Students liked it.