There are many benefits of medical abbreviations. One benefit of medical abbreviations is how much easier it makes it to read a chart. This speeds up the process by knowing the abbreviations and the use of them. It is nice to simplify things by using medical abbreviations when it is a busy day. The other reason to use medical abbreviations is so that only the medical personnel will know what is being described. It is a very efficient way of maintaining a patient’s privacy. Everybody does not need to know a patient’s medical history or what is going on with a patient or resident and allows their privacy to be protected.
Limitations of Medical Abbreviations There are often more than one meaning for an abbreviation, which in turn can cause confusion if the person tending to the patient is unaware of their medical history. An example being the letters EP. This abbreviation could mean either an ectopic pregnancy or evoked potential. If the person reading the chart is not careful, a mistake could be made. If a doctor were to write and incorrect dosage, it could lead to several different complications or health problems, and even death. A person reading a dosage incorrectly may also have the same result.
Abbreviations that support Jane Dare’s treatments and diagnosis would be dosages for her medications. Also, the HEENT for the head, eyes, ears, nose, and throats exam which showed the doctors difficulty in examining her. Knowing that Jane Dare had an EKG and a CBC prior to being released into a skilled nursing facility helps staff learn about her history. Because she was having trouble with ADL’s, it helped the therapists by informing them of things they need to help Jane Dare work on. Also knowing that Jane was still experiencing SOB, could be an indication that she will need oxygen when she is ready to be released home.
I feel Jane Dare is angry and aggressive because she fears she is dying. She misses her husband and wants to return home to her him, but does not understand that he is unable to take care of her. She has sever end stage cardiomyopathy and is taking it out on her caregivers because she is very aware of this. Even though the caregivers have her best interests at heart and are doing what they can to help, Jane believes they are the ones keeping her from going home. There were a few abbreviation mistakes that I noticed. There were no ICD-9-CM codes on the admission summary sheet.
These codes are used for billing and the absence of these codes would cause her provider not to approve of her billing. The second mistake noticed was that all diagnosis were principle diagnosis and no secondary diagnosis. Which was the main reason for admitting Jane Dare, Congestive Heart Failure, left pleural effusion, or pneumonia? There should almost always be a secondary diagnosis with a primary. Another mistake noticed is the kind of antibiotic used when Jane was pit on an IV. Was there sulfa in it, considering Jane is allergic? Why was a blood culture not collected?
If Jane was not able to sleep in her room because it is too hot or cold and the staff has found her sleeping on the floor, how do they know that she did not fall during the night? In RAP #8 it says that Jane needs the assistance of 1 to ambulate, however, the next statement reads that in a wheelchair she must be pushed to and from all locations because she gets SOB when doing it on her own. If she is able to ambulate, why is it she is having trouble in a wheelchair? Also, if psychotropic drugs are causing problems, why hasn’t the dosage been reduced or even stopped all together?