Jane Dare's Health Record Summary Essay

Abbreviations are used a lot of times in the art of medicine worldwide. Medical abbreviations are so numerous that no medical personnel can claim he/she knows all. New terminologies are coined continually and once they gain acceptance, they are used in conjunction with the traditional ones. It is often said that these abbreviations save a lot of time when documenting patient’s information, progress notes and management. Some of the commonly used abbreviations include BP which means blood pressure, HEENT which is an abbreviation for head, eyes, ears, nose and throat, PERRLA means the pupils are equal, round and reactive to light. MI could refer to mitral insufficiency or myocardial infarction. At the same time, abbreviations could be risky when information is misinterpreted and it occurs frequently. When this happens, it alters the patient’s management line and eventually the outcome of the patient’s illness. For an admitting diagnoses of congestive heart failure, left sided pleural effusion and pneumonia, abbreviating could spell doom for the patient and the management team. In the case of Jane Dare, SOB was documented as the presenting complaint. SOB as the presenting complaint is both ambiguous and confusing. It actually means shortness of breath while at the same time could mean a different thing entirely. It could be very difficult for someone not there when the patient presented at the hospital to quickly decipher the meaning. The above diseases are acute, life threatening diseases that require all the patients’ details from the minutest complaint to the gravest of them. This singular abbreviation could have altered the diagnosis and management of Jane dare. Also, in the course of an emergency, the medication dosage abbreviations could be challenging, resulting in over dosage of drugs which could become fatal.
In conclusion, though abbreviation could be time saving, it should be discouraged in its entirety and doctors and members of their medical team should be encouraged to take their time in documenting well and doing so legibly as these acts could make or mar their patients lives.