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PTA Blog Talk

Patient Notes

Published May 26, 2011 2:50 PM by Jason Marketti

"MAMPU." I came across these letters several years ago while working at a hospital. They seemed common enough because they were repeated in the physical therapy daily notes under different days. I had never seen them before and asked for an interpretation. "Multiple attempts made, patient unavailable."

There was no other description or explanation of why the patient was not seen. Other places I have worked would write the reason why the patient was unavailable, i.e., patient at X-ray, surgery, transferred to ICU etc. A line or two of narrative explanation about why a person was not treated can be helpful to the person who follows in a therapy session.

When I went to work at a new hospital, I had carried over some bad habits of writing in code. One of them was "UIC" meaning "up in chair." The PT who treated the person the next day asked me about it and thought the U was a V and wondered why I was using a certain vapor rub on the patients after treatments. It took several years to break some of the bad code habits I picked up right out of school.

I still have the booklet of acronyms from my very first job as a PTA. The 100 pages covered each department of the hospital, using every conceivable letter combination. I thought I had struck gold until I realized each new employer has its own set of approved acronyms. I will occasionally fall into using some of them but with computer documentation the norm, I find it easier to write the whole words out instead of using our medical shorthand.

The other problem I have is mixing in texting shorthand when typing patient notes. I have done this once or twice and have to go back and edit my notes because I have inserted a number instead of a word. "Mayb we can mrg tha 2 somday n it wil b aceptbl."

2 comments

I remember going through this on student rotations.  I felt like I needed to take a foreign language course before my first day at a new site!  One facility gave me a multi-page handout of acceptable PT department abbreviations I had to learn asap :-)  Unless I was positive an abbreviation was on one those pages, I was forbidden to use it.  I guess they had experienced repeated problems with student documentation and decided to be proactive.

Because of my student experiences, I determined to minimize my abbreviations to only the most commonly accepted, but even found those tripped up some.  For example "with" and "without" can both be abbreviated two different ways.  Which one would I use?  I figured either would be common enough that anyone would know them.  I was wrong.  It would appear that "common" abbreviations are no more common than "common" sense!  

Your texting example was cute-would have never crossed my mind as an issue.  While I had to make a concerted effort not to use abbreviations in the clinic, I have a hard time bringing myself to abbreviate in texts.  I feel like I'm being a slacker if I don't type out the whole word.  Go figure!  

Janey Goude June 2, 2011 2:28 AM

I am guilty of the same thing...but not to that extent. You have highlighted the very rationale behind JCAHO's crusade against abbreviations. Mistaken meanings can result in patient errors. Even when you are diligent about only using a facilities accepted abbreviation list, there is still the new person who may not know what you're trying to say. I HATE writing out long hand but...I'm trying to mend my abbreviated ways too.

Dean Metz May 26, 2011 11:23 AM

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About this Blog


    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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