Thursday, February 23, 2006

What?

Saturday was my day off. I decided to spend part of it catching up with my brother who recently ventured off on his own and began a startup internet price engine. We spoke about the business and the general state of the market.

During the two hour conversation he told me about how "spiders” were “continually crawling his site” and “indexing pages” into the search. How he had to track “IP address” and other “browsers” to determine charges that would be incurred. This incomprehensible soup was spewing out of him like honey. Had I the guts to explain I understood but a simple portion of our initial conversation and nothing else (Specifically, when we exchanged goodbyes) I would have endured an hour long lecture. But the experience truly shocked me, the exploration of my internet age ignorance that is.

When did it get to this? We speak English mostly everywhere but even our English is divided into Spanglish, Slang and Rap. Then there's Ebonics and Spanish and in certain areas you can't get along if you don't speak the local vernacular.

I am so glad that as a part of the medical community we are not privy to these types of miscommunications, everything is plain and simple. Our vocabulary, an example of brevity and clarity.

So, the other day when a Surgery consult came to ask me to clarify what was written in the chart of a patient I had recently admitted I stared at him in sudden disbelief. Why it’s clear as night and day. The chart read, "64 y/o m was in USOH 2 d/ PTA, BIBEMS w/ c/o pain in LE and SOB, please r/o DVT/ PE. Obtain duplex, get a V/Q, D-dimer and spiral CT/ PE Protocol".

Where did this guy come from, Mars?

An oldie but goodie from the archive. Check the comment section for an explanation of the chart.

40 Comments:

Blogger Internal Medicine Doctor said...

64 year oild amle in his Usual State Of Health (USOH) 2 days prior to admission (PTA), Brought in by EMS (BIBEMS) with (w/) complaints of (c/o) pain inn the Lower Extremities (LE)and Shortness of Breath (SOB). Please rule out (r/o) Deep Venous Thrombosis (DVT)/ Pulmonary Embolism (PE). Obtain duplex get a Ventilation/ Perfusion scan (also called a V/Q scan), D-dimer (blod test) and spiral CAT scan.

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Blogger Dreaming again said...

I understood way tooo much of that for a lay person .. thankfully, not all of it.

5:36 AM  
Anonymous Kel said...

We are verboten from using abreviations in our pre-cardiac catheterization H&P's and cath reports.

We can say Left Anterior Descending (LAD) and then use LAD throughout the rest of the report.

Our powers that be tell us that our outside referal base like english and it looks "classier." Of course it adds another 10 minutes to each pre-cath H&P that we type.

8:37 AM  
Blogger incidental findings said...

Our hospital goes by a list of acceptable abbreviations (theoretically) that most of us stick to.

No one gave the neurologists that list though.

11:40 AM  
Anonymous DawnCNM said...

I could read most of your admit note, but BIBEMS was a new abbreviation for me! The rest I knew. Love your blog, even though I usually just lurk.

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Anonymous Medic-of-one said...

*snerk*

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Blogger Drinkysr said...

The tragedy of using abbreviations, and in the cases of transcriptionists, macros, is that some abreviations have more than one meaning. This led to an embarassing error when a few days after seeing a "31 year old black male" in the ER, I went to sign my dictations in medical records only to find I had carefully attended the needs of a "31-year-old bowel movement".

Fortunately for Mr. Hanky, I had one of Chef's chocolate salty balls on hand....

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