In the hospital, it takes some practice to learn how to read a patient's chart. First of all there's the handwriting. I have absolutely never understood why doctors write in charts with such BAD handwriting. You would think that if they wanted to say something important about the patient, they would write it legibly. For instance, if a patient had a DVT, or was being ruled out for a PE, or was s/p R THA, I'd want to know about it! because I wouldn't get them out of bed! Or if I did, I'd use certain precautions!!!!
Most of you are probably wondering what DVT, PE, s/p, and R THA are. Well, that brings me to the point of my BLOG. All the abbreviations in the charts. What I love to call Alphabet Soup! You really have to know another language to understand the chart. And while initally a pain in the buttocks, it ends up being easier than writing it all out. A DVT is a deep vein thrombosis, a PE is a pulmonary embolism, both BAD to have. A broken off DVT can lead to a PE and kill you. s/p is status post, meaning they just had something done, a THA is a Total Hip Arthroplasty, of hip replacement.
So, I may see a patient with the following in their chart. Lets see how much you know.
Pt is a 78 y/o WM, admitted 1/2/34 with c/o n/v, and BRBPR. Pt has h/o NIDDM, CHF, COPD, CAD, MI with PTCA, CABGx3, BPH with TURP, and L TKA. Pt was admitted with a dx of LGIB. Pt had a abd CT, CXR, an colonoscopy and and an ECG. His H&H was ## and ## therefore h received 2 units PRBS's.
I may see an activity order that says BR with BRP tonight, OOBTC in AM with Assisatance.
WHAT? Well, alphabet soup tells me that a 78 year old white man was admitted on said date complaining of nausea, vomiting and blood in his stool. BRBPR means bright red blood per rectum. This patient has a past medical history of non-insulin dependent diabetes, congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, myocardial infarction (heart attack) with percutaneous coronary angioplasty. He's also had a coronary artery bypass graft to 3 arteries in the heart, he's had benign protastatic hypertrophy, with a trans-urethral removal of the prostate, and he's had a left knee replacement. He was admittedbecause of a lower gastrointestinal bleed. While in the hospital he had a cat scan, a chest xray and elecrtocardiogram. His hemoglobin and hematocrit was said number, and it must have been low due to the gastrointestinal bleed, so he recieved a blood transfusion, 2 units of packed red blood cells. He needs to stay in bed tonight, but has bathroom priviledges, meaning he can only get out of bet to go to the bathroom, and tomorrow morning he can get out of bed to the chair with assistance.
Now, isn't it easier to say it the first way?
I'm learning to like alphabet soup. I can usually figure it all out after working int he hospital almost 9 months, but I still need my Little Red Book sometimes. It's the best thing I've ever gotten, its a medical abbreviation dictionary. And I carry it everywhere I go. Well, in the hospital at least. So while I needed to learn to love alphabet soup, I still get some help from time to time. WHOO HOO for my LRB!!!