Tuesday, October 26, 2010

Shorthand for Palliative Care Professionals

As EMR's move closer to becoming sentient beings that will eventually control the world, which at the current pace of their development I would estimate to take another 643 years, I have noticed a change in how I take down details about my patients as I round each day.  With a paper note I would typically write down information on the actual progress note I expected to put in the chart.  Therefore the information I wrote would have to be in the final (hopefully) legible form.

But with a EMR, I find there are times when the clinical day is so busy that directly entering the note right after the clinical encounter is difficult to do with out jeopardizing or delaying the care of other patients, so like many other clinicians I have talked to or seen we are left charting at the end of the day, transferring information from our brain, and our hasty notes into the EMR in the final (very) legible form. I also use these shorthand techniques when taking notes from nurse in the field calling to collaborate. 
So I thought I would share a few of my shorthand techniques and see what else the palliative care community had to add.  Now we are not just talking about simple abbreviations here like DNAR = Do Not Attempt Resuscitate, but more complex system, although not nearly as complex as Gregg Shorthand.

So here are a few of my shorthand notes:

F25 = Fentanyl 25mcg patch q72h (The 72 is always assumed, but if the patient is on q48h, I usually put a dash modifier after the number, like this F50-)

R5, R10, R510, R1020 = Roxanol (liquid concentrated morphine) with one or two digits equaling a non-ranged dose, and R1020 = Roxanol 10-20mg.  Q1h is assumedas a common dosing interval in hospice.

MS = IV/SQ morphine, never PO/SL since that is R

M = methadone (assumed oral unless written otherwise)

HM = hydromorphone (Dilaudid) IV/SQ.  Chose not to use the  D so not to confuse with 0

hm = hydromorphone PO/SL.  Used lowercase since it is not as strong as IV/SQ per mg dose

Oxy = oxycodone
OxyLA = oxycontin These two are fairly obvious.

H = haloperidol I do not make a distinction in the abbreviation here or for lorazepam for route and usually will add route after.  So H12-4 = Haloperidol 1-2mg q4h prn

L = lorazepam
SC = scopolamine patch q72h
G = glycopyrrolate (not 'R' because that would be roxanol)
A = atropine (since L = lorazepam)
B = benadryl
C = compazine
Z = Zofran
MNTX = Relistor (methylnaltrecone)
S/S = senna - s with the number of tabs am/pm indicated after S/S 2/2 = Senna-s 2 tabs Twice a day.

PCA shorthand
I have tried a couple of different systems but the one I think that works best is

HMPCA 2 / C2-60/ P1-30 = Hydromorphone PCA with 2mg/hr basal, 2mg q60min Clinician bolus PRN, with 1mg q30min Patient bolus.

Other examples MSPCA 3 / C5-60 / PØ  ( If there is no clincian bolus or Patient bolus I use a line through a zero.

Scheduling vs. prn
If a drug is scheduled then I will circle the interval, so Haloperidol 2mg every 8 hours scheduled would look like H2-8 (with a circle around the eight)

Family meeting shorthand
When everyone is doing introductions, I try and write everyone's name down with out looking at the paper, so I can have reference later in the meeting if I need to address someone.  I add the names in the pattern they introduce themsleves so I ahve a little map to refer back to after the meeting.  I never worry about spelling peoples names and usually will just try and spell phonetically as or include a few letters. So William = Wm; Brenda = Brda, Allison = Alsn, etc. Usually that is enough for me to remember them later on when the official note is written.  But it is important to know the relations so for family relations I use the following key after the persons name.  Most of the following are obvious but there are a few tricks.

H = husband
W = wife
SO = significant other
SIL = sister in law or son in law.  Check the name to tell the gender
DIL = daughter in law
BIL = brother in law
S = son
D = daughter
M = mother
F= father
G = grandparent
F = friend
N = neighbor
A circled name = DPOA
P = anyone on a speakerphone during the conference
I add the state two letter abbreviation for any out of town relative present
OOH = out of hospital DNR form

Do you have any that you use regularly? I will add more as I recall them day to day.

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