Documentation is a most important aspect of your craft as an Emergency Department nurse. The ability to communicate fluently and accurately is not only an essential competency, it is a legal fingerprint of the care you deliver.
So… you should make your charts, history’s and notes a justifiable reflection of the quality care you deliver.
With this foremost in our minds, we present the following list of useful acronyms to add to your literary kitbag.
Use them to squeeze some vital juices into your notes. Use them to add an objective and accurate sub-context to your reporting. Use them to tell it like it is. Use them at your peril.
Alert, Oriented times 3 (person, place, time).
Apoplexy, Epilepsy, Injury, Opium or other drugs, Uraemia, Dead Drunk and Diabetes. ( mnemonic to aid memory of possible causes of unconsciousness.)
All fine on leaving.
Acute Gravity Attack. (Patient fell over)
Assuming Room Temperature. (dead)
All Well On Leaving.
Away With The Fairies.
Big Boobs, See Soon.
But Unfortunately Not Dead Yet.
Breathing Valuable Air.
Beached Whale Syndrome.
Circling the Drain/Close To Death.
Danger To Shipping.
Dead Right There.
Dead Right There, There, There, and There.
F****d In The Head.
Funny Looking Kid.
Friggin’ Nearly Died.
Fornicates Regularly And Chain Smokes.
God Alone Knows.
Get Out of My Emergency Room.
Husband Is Village Idiot.
Normal For Nurses.
Not One Of Nature’s Gentlemen.
Not Quite Right.
Not Yet Diagnosed – Nervous.
Oh Shit I Never Thought Of That.
Pissed And Fell Over.
Pressured And Not In Control. Descriptive and useful acronym for all sorts of situations. A reminder also that pressure alone does not produce panic – it’s whether you can control it.
Patient Reassured And Told to F**k Off.
Stroppy Ignorant Git.
Shortness Of Breath.
STIO/SIO SupraTentorial in Origin. (psychosomatic)
Tired All The Time.
Tried Everything Else?..Try Homeopathy.
Take Out Back And SHoot.
Told To F**k Off.
Totally Unnecessary Breast Examination.
Total Waste Of Frigging Time.
Unexplained Beer Injury.
Unusually Nasty Infection; Vultures Are Circling.