The nursing school brought about a new language and a new way to write this new language. Several words I heard before ambulation, and void being a sample, but never in an everyday dialog. The writing of these new words was also a complete mystery to me. I found at the end of each lecture; I needed to start a list of the words that, at the time to me, looked like a meaningless grouping of letters. All of my notes had their margins filled with the meanings to the abbreviations. Eventually, from seeing the same abbreviations over and over, you do learn the most common ones.
The abbreviations make it easier and quicker to write information about a patient. The use of HTN for hypertension, considering the number of adults with hypertension saves time, as a student but also as a nurse writing the history of my current patient, or GERD for gastroesophageal reflux disease. Just about every disease process has an abbreviation. A patient with a long list of health conditions can be read and written quickly, whether before a shift or during the report.
The issue with an abbreviation is that they are just letters. The medical field is as vast as will begin to splinter into its specialty fields and develop abbreviation used for these conditions or procedures. A nursing professor told her own story of being on a medical-surgical unit with a group of students; this nurse had worked in labor and delivery for years. She looked up a patient and found herself confused that the notes stated a “74 y.o male with ROM…” The 74-year old male wasn’t the confusing part, but coming from the background of labor and delivery, ROM meant Rupture or Membrane, whereas here it was meant as Range of Motion. Two completely different things. Now since the 74-year gentlemen, more than likely, did not have his water break, deduction states that it was “range of motion.” The other issue with abbreviations, typically comes from when people were using written charts, so important information was being seen as something completely different, or misread. The use of computers seems to help with some of the ill-written problems that deciphering a physician’s progress report or other nurses’ notes hold the potential.
Fixing the problem with the abbreviation, throughout school, I kept hearing the term approved medical abbreviations. I have never found one list of approved abbreviations. I have found a “Common list of Abbreviations,” or a group of hospitals “approved list” but not an all-inclusive list. What I did find in my research was a Do Not Use list from the Joint Commission. The DNU or Do Not Use list places the items in a table showing the abbreviation, what it gets mistaken for, and the proper way to use it.
So it seems unless it’s on the list from the Joint Commission or your organization’s list abbreviations can be just about anything. As a student, don’t worry, this is like a new language and writing style. The more you use it and not the abbreviations, the more it will start to stick, and you will use it as well. As for the common abbreviations, there are many times my brain takes a minute and an abbreviation that I had seen and used myself, I can’t remember. Don’t be afraid to ask or look it up.