"DENIES PAIN, NAUSEA. SBA OOB TO BR. GOOD UOP. ON HEP GTT. FATHER AT BEDSIDE. INCISION CDI. TOLERATING CLEARS. + BT, PASSING MINIOR GAS. ABD SLIGHTLY DISTENDED. WCTM"
I saw this nursing note on a patient today and thought....wow, look at all these abbreviations. We all use them but .... This note is code for....
"Denies pain, nausea. Standby assist out of bed to bathroom. Good urine output. On heparin drip. Father at bedside. Incision clean, dry, intact. Tolerating clears (liquids). Positive bowel tones, passing minor gas (farts). Abdomen slightly distended. Will continue to monitor."
Good thing I know the code. There are still times that I find one that stumps me and I ask a colleague. But, not often. How about our favorites in Nephrology?
CKD: chronic kidney disease
LRT: living related transplant
DDT: deceased donor transplant
PKD: polycystic kidney disease
and the secret ones we never write....but occasionally speak
FOS: full of shit (literally)
PPP: piss poor protoplasm