As Hamlet said.
One of the coolest things about working in the medical field, is the freedom to document in incomplete sentences and use medical terminology. I was never a stellar Grammar or English student, and I always abbreviated like mad when I took notes in History class so I view medical terminology/ documentation as a thing of beauty. Did you know Medical jargon has a word for almost EVERYTHING? Here are a few examples:
Bloody nose= Epistaxis
Dry Mouth= Xerostomia
And one just sounds more competent saying, “I noticed slight ataxia when she was ambulating in the hallway post-op.”
I love being able to abbreviate when writing at work, and believe me there are days when it saves me from overtime. In nursing school it was drilled into our overflowing little heads, “If you didn’t document it, it wasn’t done!”. On certain days the when list of progress notes to write is obscenely long, it’s a little blessing to know I don’t have to document using APA format and proper grammar. A sampling of medical abbrevs:
@= at ABD= Abdomen p (with a line over it)= after a (w/ line over it)= before s (w/ line over it)= without Tx= treatment C/D/I= clean, dry, and intact HRR= ♥ rate regular I could go on and on, but will stop here. Hope you learned something new!