[Music] hi it's sarah you're ready next door i'm a doctor in australia today we are going through some medical abbreviations i've named this series mate we use so many medical abbreviations day-to-day in clinical practice it's sometimes a bit ridiculous but it does help us make documentation more efficient i have so far compiled a list of more than 200 abbreviations and i hope to break them up into categories today we're covering common abbreviations that you will see on patients progress notes the video is set up in a quiz format where i get you to guess what the abbreviations stand for followed by the full word or words and a brief explanation let's go let's start with this one can you guess what this stands for did you get it right pt stands for patient rv stands for review review is anonymous to assess you review patients when you check up on how they are doing hate x hatred stands for history history is basically the story the patient's story about their medical condition or symptom pc pc stands for presenting complaint presenting complaint is the main problem that the patient is seeing you about for example presenting complaint may be chest pain or itchy skin hpc hbc stands for history of presenting complaint history of presenting complaint is the story in detail surrounding the patient's presenting complaint if the patient's presenting complaint is chest pain you would ask all the relevant questions about their chest pain phen paychex pmhx stands for past medical history past medical history is all about the patient's past medical history for example if the patient's presenting complaint is chest pain you would want to know if the patient has had a previous heart attack and what happened to treat their heart attack shx s h x stands for social history social history is about all the non-medical things about the patient that is important for us to know to best care for the patient common questions i ask my patients are regarding their living circumstances where they live who they live with whether they use a mobility aid if they have any paid services that come into their homes to assist with shopping cleaning cooking and personal hygiene whether they smoke cigarettes drink alcohol or take recreational drugs oe oe stands for on examination after oe i document my examination findings which includes the patient's vital sign and the physical examination findings like what their lungs sounded like and how their wounds appear to you tx tx stands for treatment treatment as the name suggests is a treatment that you provide to a patient if i give my patients pain relief and intravenous fluids i would document them under treatment mx mx stands for management this is similar to treatment cx cx stands for complicated we use this when we want to mention if their condition or treatment was complicated by something check out the example on the slide pdx pdx stands for provisional diagnosis after a doctor takes a history does an examination and performs some investigations the doctor will have some idea about what the patient's main problem or diagnosis is provisional diagnosis is their first impression on what the diagnosis might be ddx ddx stands for differential diagnosis when doctors think the patient's problem can be due to multiple different diagnoses they document a different differential diagnosis stating all the different possibilities for the patient's problem rxn rxn stands for reaction rf rf stands for risk factor risk factors are patients age sex or condition that may be that may predispose them from having a disease or medical condition atsp atsb stands for ask to see patient this is usually used by doctors and seen at the top of their documentation when they are asked to see a patient by a nurse regarding a particular problem for example the nurse may ask a doctor to review a patient for a low blood pressure atrp atrp stands for ask to review patient this is the same as atsp c o c o stands for complaining of this is used when patients are reporting certain symptoms or used in other ways when patients literally complain about something it may appear to have a negative connotation but it simply means patients are reporting or stating something they are concerned or worried about however it can sometimes be used in a literal way s-o-o-b s-o-o-b stands for sit out of bed this is literal when doctors or physiotherapists want a patient to get out and sit out of bed they would document s-o-o-b in part of their plan this is important activity for otherwise bed-bound patients it also helps patients get into a routine and helps to limit daytime sleeping tod tov stands for trala void tralavoid is done for patients who have indwelling catheters which is a tubing that goes through a patient's urethra and sit in the bladder and allows urine to drain freely into a collecting bag there are many indications for indwelling catheters doctors were instructed that the indwelling catheters are removed at which point the patient goes through a trello void process which is simply seeing whether patients would be able to empty their bladder on their own without the catheter et et stands for exercise tolerance exercise tolerance is another way to say how fit the patient is it helps healthcare workers to understand what level of activities the patient are capable of when they are well it is a good way to gauge how the patient's current illness is impacting their level of activity a measure of how unwell they are nbm nbm stands for nearby mouth neo means nothing patients are made nearby mouth for several reasons for example they may need to fast before surgery or stroke patients may be made nearby mouth if their swallowing is impaired cfd cfd stands for clear fluid diet you may see this abbreviation on the surgical or gastrointestinal wards it is a special diet patients are put on examples of clear fluid items are water tea and apple juice ffd ffd stands for free fluid diet this is another abbreviation seen often on surgical patients example of free fluid items are milk and custards ot ot stands for operating theater nh and h stands for nursing home hash symbol hash symbol stands for fracture as in fracture of bones cpr cpr stands for cardiopulmonary resuscitation cardiopulmonary resuscitation is a procedure where you provide chest compressions when a heart stops fading in efforts to restore blood circulation dnr dnr stands for do not resuscitate a dnr order is placed on patients who have either expressed that they do not want to have cpr performed when their heart stops or deemed to not benefit from cpr due to their underlying conditions acp acp stands for advanced care plan or planning advanced care plan is a broad term that encapsulates the process and documentation of what the patient wants in their future healthcare when they are no longer able to express their wishes verbally it helps family and healthcare professionals make decisions about how to provide healthcare to that individual when he or she loses their capacity to make decisions acd acd stands for advanced care directive advanced care directive is similar to advanced care planning in the sense that it outlines or risks about future health care the difference is that a directive is a legally binding document that provides instructions about the patient's future medical treatment different states have different requirements surrounding the advanced care planning and formulation of advanced care directive check out advancedcareplanningplanning.org.au for more information adl stands for activity of daily living activities of daily living or activities like shopping cooking cleaning and activities related to personal hygiene it is a way healthcare professionals can understand how a patient's medical condition affects his or her function at home d-a-m-a dama stands for discharge against medical advice discharge against medical advice is when a patient who has a capacity to make decisions about his or her health care leaves the medical facility and refuses treatment against the doctor's advice dnac or dnac dnac stands for do not attend call you will likely see this used in the emergency department sometimes patients that have registered themselves to be seen by a doctor decides to leave the emergency department for whatever reason before they are formally discharged and are unable to be located in the facility in this instance we say the patient has denact aws aws stands for alcohol withdrawal scale alcohol withdrawal scale is based on a series of criteria to assess whether the patient is withdrawing from alcohol based on the score the patient is given treatment to help with their withdrawal eth e-t-o-h stands for alcohol indeed i say more that's it for me today there are tons more abbreviations i'll be covering in the future if you're not from australia let me know in the comments below the different abbreviations you use that is different from what i covered 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