Do you use medical shorthand, or slang in your reports, or do you write the words out? Do you feel it is safer and more professional to write out your entire report as oppose to using these little easy to confuse symbols?
The pt came in c a C/C of a cc of fluid in his ear! We must txp to tx his sx!
Get me that sat, STAT!
Personally I am guilty of using s with a line and c with a line for without and with, it's also occasionally snuck into a text message (minus the line) but try to avoid all others. I know it's still a bad habit and I should break it.
I use only the pre-approved company allowed shorthand, and only if I know what it is off the top of my head and can recall it when asked, without looking it up.
Be aware hospitals and EMS may have a few differing abbreviations.
Some abbreviations also mean different things to different professions.
As well, don't assume everyone knows the ALS vs BLS stuff or all the many titles given to EMS providers.
Medications should be written out clearly.
Dosages should read: 0.5 and not .5 which could look like 5.
Even O2 can be an issue for CCT, Specialty and some IFT since there are several different gases used. Even in homecare don't assume that tank is oxygen as some patients are also on nitric oxide.
Slang like "sat" is not appropriate documentation. Use Pulse Oximetry or SpO2.
I abrivate certain things. "Abdominal Pain in the upper left quadrant with guarding and rigidity to the touch " becomes "abdom pain, ULQ, rigid to touch and guarding."
Otherwise, I write out MOST stuff. I have noticed I use more acronyms and abbreviations the deeper I get into ALS, though, because my narratives end up that much longer.
I use the more common abbreviations from our list of approved ones. Around here, we basically have the same list as the hospital, so only JCAHO approved abbreviations, and honestly, there are only a handful of them that I do use. That is because I won't use an abbreviation that I am not familiar with/don't typically use. I write everything else out. If I need a second page to add to my PCR, so be it. (And lately, I have been using our page 2 ALOT!)
The way I see it, the more you write out, and the less you abbreviate, the more clear your narrative is to those who are reading it.
I agree 100%. Abbreviation leads to confusion. Not everybody is knowledgable when it comes to abbreviations (even the standard and basic) so why risk it? I never assume because we all know what happens when one assumes. LOL.
Abbreviations save time and time is someone's life. The sooner we finish paperwork, the sooner we are clear and ready to go on another call. It doesn't matter though, we use a software program for our reports.
If your system is so backed up that you don't have enough time to do paperwork properly (outside of the debate on abbreviations), then you need more ambulances.
We are still using archaic paper report forms so yes we do abbreviate but only to the consensus of accepted western medical terminology -- e.g. pt/cc/hx/htn/tia/ami but drugs generally get written out in full anyway.
There is one I remember using, which I don't think you use in the States. Correct me if I'm wrong!
# Which means fracture. It's a lot quicker writing 'pt has susp # to R Humerus' than' Patient has suspected fracture to the Right Humerus'.
The most important thing was that the ED (ER), knew what we were talking about.
There is a state approved list of abbreviations that we can use for all agencies.
There is a DO NOT USE list as well published by JHACO or something like that.
Finally, my employers have said use whatever you want as long as its consistent, not confusing, and appropriate. If something is wrong they'll point it out. For example, instead of 'c' and 's' I use "w/" and "w/o" respectively. Just how I learned it growing up. As long as use use it consistently, and when called upon to explain your report (say to a nurse, billing department, or by a big scary guy wearing black robes in front of 12 angry men... then you should be ok.
That being said, make sure your abbreviations are not confusing! Most of us have written ehough reports and have gotten enough feedback about them to know what is ok and not.
