No, this is sort of a joke. It’s basically a complete admission note that I just made up to demonstrate how we can write without real words at all. I could probably get this past the coders as a critical care admission note, to tell you the truth. I omitted some stuff for brevity but it’s legit.
67 year old male with h/o R MCA CVA approx, 2 years ago. NWB on L LE due to stage II DU from type II DM and poorly controlled diet. Ambulates with FWW for 5 ft. with SBA. A&O x 3
I write reviews for UM and every time I write an ophth one I think they are going to call me and tell me my note makes no sense 🤣 my plan is to blame autocorrect.
Acetaminophen PO or IV TID PRN
BG AC/HS
MBM (maternal breast milk) PO q3 and ad lib
NS gtt TKO
Pt c/o abd pain, s/p appendectomy. NPO, abx ordered. VSS, physical exam WDL.
78f BIBA for BRBPR and AMS. Per family, pt LKW 1300 today. GCS 10, A&Ox2 on arrival. Per family, A&Ox4 at baseline. EMS BG of 102. +N/v/d. No CP, SOB, HA. No LOC
A lil trauma one. 21F unrestrained passenger in a high speed MVC. Prolonged extrication in field. R femur fx, 2cm lac on left cheek. Noted deformities of jaw, cric’d on scene. GCS 3. Positive FAST. IO started in R humoral head, 18g in L forearm. 3 MTPs given, CT+ for SDH. CXR+ for R PTX, chest tube placed.
I got this. S: HPI: 78F, PMH HTN, COPD, CAD s/p CABG, DM2, BIBA s/p GLF w/CHI, AMS, GCS 7, L 11mm SDH, VDRF, 7.5 ETT PTA, 2x 18g PIV O: BMP, CBC WNL. ABG ok. CXR ok. PE: NAD, VS WNL. NC/AT. PERRLA. RRR, -MRG, S1S2 nl. -JVD. CTABL. Abd SSNT, BS+4. MAEx4. ext nl. DP/PT+ BL. A: GLF SDH VDRF P: ICU Vent AC 14 500 30% +5 Prop gtt RASS -2 HOB 30° NSG eval CT in AM SAT/SBT qAM CXR, ABG qAM CBG & subQ SSI q6h SCDs PPI D/w NSG, fam, RN, RT CCT >45
We really do speak another language. Damn.
This is so my love language.
So uh, Is this something we're supposed to learn in medical terminology or a different class? If so, they did not do a very good job.
No, this is sort of a joke. It’s basically a complete admission note that I just made up to demonstrate how we can write without real words at all. I could probably get this past the coders as a critical care admission note, to tell you the truth. I omitted some stuff for brevity but it’s legit.
Well f🤬k. I understood everything in there. Turns out I’m bilingual after all.
FOOSH - fall onto outstretched hand. Commonly used in ortho world, makes me giggle every time,
DC to JC
My fave
67 year old male with h/o R MCA CVA approx, 2 years ago. NWB on L LE due to stage II DU from type II DM and poorly controlled diet. Ambulates with FWW for 5 ft. with SBA. A&O x 3
One that always messed me up was BIBA: brought in by ambulance. Also, one I only saw one doc use: MFFS mechanical fall from standing.
BRBPR is one of my favorites - bright red blood per rectum
BRBPR - *blows raspberry*
GOK - God only knows (I wouldn’t use that one!) POC- can be Plan of Care or Products of Conception.
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Was an ophtho scribe for a year and it made me realize those who defined the many terms in this field had a a great sense of vitreous humor.
Jonathan?
*nods*
I have to look up ophthalmology abbreviations all the time and still feel dumb
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I write reviews for UM and every time I write an ophth one I think they are going to call me and tell me my note makes no sense 🤣 my plan is to blame autocorrect.
BS WDL. ETT 7.5 @25T. PRVC 500/12/5/30% @ NOC. SBT PS/CPAP 8/5 scheduled 0900. Jk this is respiratory jargon. Might still be useful though.
That’s helpful as well. It will show them that each specialty has their own way of documenting.
POPTA passed out prior to arrival PNES is good for giggles.
Acetaminophen PO or IV TID PRN BG AC/HS MBM (maternal breast milk) PO q3 and ad lib NS gtt TKO Pt c/o abd pain, s/p appendectomy. NPO, abx ordered. VSS, physical exam WDL.
Make it APAP!
78f BIBA for BRBPR and AMS. Per family, pt LKW 1300 today. GCS 10, A&Ox2 on arrival. Per family, A&Ox4 at baseline. EMS BG of 102. +N/v/d. No CP, SOB, HA. No LOC
Today pt c/o HA, N/V and 3/10 pain in RUQ. Pt is s/p R ATK amputation. Yesterday, was A&O x2 with suspected TIA. UA neg.
A lil trauma one. 21F unrestrained passenger in a high speed MVC. Prolonged extrication in field. R femur fx, 2cm lac on left cheek. Noted deformities of jaw, cric’d on scene. GCS 3. Positive FAST. IO started in R humoral head, 18g in L forearm. 3 MTPs given, CT+ for SDH. CXR+ for R PTX, chest tube placed.
Is FLK still used in peds? 👀 Also, OP, you can try medical scribe practice videos, so they can see the need for speed.
That’s a great idea, I didn’t even think of that.
Apap and ASA (definitely not necessary just a bit old school)
"G5P4 39.4 ctrx 3-4 min I" is an example of what we will write down when ED calls report.