Do these four lines make sense to you? If it does, then you must be a physician. During our recent TJC inspection, one of the things they were looking for was legible handwriting by doctors. Not only did the notes have to be easily read, they also had to make sense. No bizarre (nonstandard) abbreviations were allowed. If they came across one in your notes, you were tracked down and educated on the necessity of good writing. It has been shown that poor handwriting leads to medical errors. These errors should never happen because the physician couldn't bother to clearly differentiate between "mg" and "mcg" in his orders.
87 y/o AAM w H/O CAD, IDDM, HTN, BPH, ESRF and CVA c/o BRBPR x 7D
PSH: CABG, TURP, AICD, AVF
Soc. Hx: 1 PPD x 30 yrs
CV: RRR, -m
Pul: BSE, CTA
Neuro: CN II-XII int.
A/P Admit to MICU. NS TRA TKO. NPO. CBC, BMP, ECG, CXR in AM
They don't teach this stuff in medical school. In med school we had a class on medical terminology. It was mostly a semester on learning the different Greek and Latin words that are the basis of medical terms. For instance, it was important to understand the difference between "hypercalcemia" and "hyperkalemia". However, nobody taught us that OLT is short for orthotopic liver transplant or that CLD stands for clear liquid diet.
Why do doctors write such cryptic notes? Is it some sort of conspiracy to keep nurses from doing their jobs properly and thereby blaming them for any mistakes? Of course not. Principally it's about saving time. The above history and physical would be three times longer if no abbreviations were used. We doctors are so inundated with paperwork and phone calls that anywhere we can save a few seconds is worth the trouble. For every patient I see for surgery I have to sign at least five different pieces of paper. Each signature requires a date, time, a printed copy of my name, and my hospital ID number. When the cases are short and the turnover is fast, there is little time to write longhand a patient's medical history, which typically looks like the one above. Frequent use of abbreviations makes the day run more efficiently. If everybody had to write all the words out by longhand, we would be even more bogged down by paperwork than we are now.
Incidentally, the first note at the top of post means:
Awake and alert
Vital signs stable
Moving all extremities
Discharge when stable.