One responsibility that you have as an emergency medical technician (EMT) is to document your assessment and management of the patient. Such documentation can take time to complete if you write out everything that you found and performed. Medical abbreviations can help speed up the process.
You can use literally dozens of abbreviations; here are ten (or so) that are commonly used when documenting your assessment and care, plus a few symbols that you can use as shorthand for common words.
A/Ox3 (or x4): Alert and oriented to person, place, and time (if using x4, also event). Normally, people can tell you who they are, where they are at the moment, and at what point in time, such as day, date, or time of the day. This awareness is known as orientation. A change in mental status causes the orientation to change. For example, a patient may become disoriented and not remember the time or date. He would be A/Ox2 because he's oriented to person and place only.
CC or C/O: Chief complaint or complains of. This is the patient's reason for requesting emergency medical services. It may not always be the actual, true cause. For example, the patient may tell you that she's having trouble breathing; however, the real problem may be that her blood pressure is very low due to internal bleeding, and her respiratory system is compensating by making more oxygen available to the remaining red blood cells.
OPQRST: This common mnemonic helps you to remember questions related to the complaint:
Onset: What were you doing when the problem began?
Provocation/Palliation: Does anything make it worse or better?
Quality: Can you describe what you are feeling — for example, does your discomfort feel like pressure, like squeezing, or sharp?
Related/Radiation: Is there anything else bothering you? Does the pain go anywhere?
Severity: On a scale of 1(hardly bothersome) to 10 (really bad pain or discomfort), can you rate the feeling you have?
Time: How long has this been going on for? Does it come and go, or is it constant?
AMPL: This is another mnemonic that provides information about the patient's past medical history:
Allergies: Are you allergic to any prescribed medications, over-the-counter (OTC) medications, or herbal supplements? Allergies may also be related to common environmental sources, such as food, stinging insects, or pollen.
Medications: Are you supposed to be taking any prescribed or over-the-counter (OTC) medications? Be specific when asking this question. If you ask Are you on any medications?, the patient who is non-compliant with his medication may say no.
Past medical history (PMH): Do you have any past medical history, such as hypertension, diabetes, or a heart problem? A patient's PMH may be the source of the current presentation or related to it. Additionally, very common and problematic medications such as those for hypertension or diabetes can complicate the patient's chief complaint and make it harder for the patient to compensate.
Last oral intake: When did you last have something to eat or drink? This information can be valuable in determining a possible cause of nausea, vomiting or diarrhea, abdominal discomfort, or allergic reactions.
DCAP BTLS: This is a mnemonic for remembering injuries associated with trauma:
Deformities: Broken bones, dislocated joints
Contusions: Bruising, bleeding under the skin
Abrasions: Scrapes along the top of the skin
Punctures: Small openings made by something sharp, such as a nail, knife, or bullet
Burns: Soft tissue damage from heat, chemicals, or electrical or radioactive materials
Tenderness: Pain upon palpation
Lacerations: Openings in the skin; may be from blunt force that "cracks" the skin or a sharp object
Swelling: Soft tissue injury after a strain or sprain; may also be blood collecting under the skin, creating a hematoma
N/V/D: Nausea, vomiting, and/or diarrhea. These are common complaints that, if severe, can lead to dehydration and shock. Nausea can arise from a wide variety of reasons, ranging from food poisoning to medication reactions, heart attacks, and simply anxiety or fear. Vomiting is the body's way of trying to quickly eliminate something it doesn't want; it often occurs because of nausea, although patients may vomit without warning. Diarrhea is another "quick release" mechanism for something the body doesn't want. Food poisoning, infections, and certain types of medications are a few reasons for diarrhea.
NKA: No known allergies. A simple abbreviation to record when a patient denies being allergic to medications.
RUQ, RLQ, LUQ, LLQ: These point to different parts of the abdomen: right upper quadrant, right lower quadrant, left upper quadrant, left lower quadrant. Each quadrant contains a specific set of organs and structures that can cause discomfort if affected by an illness or condition. Great to use when describing where abdominal pain is located — for example, "Patient C/O RUQ pain" means that the patient is complaining of pain in the right upper quadrant.
PEARL: Pupils that are equal in size and reactive to light. Alternative abbreviations include PERRL (pupils equal, round, and reactive to light) and PERRLA (pupils equal, round, reactive, and light accommodating.) Eye pupils are very reflective of brain function. A penlight is used to shine light into one eye; normal pupils are PEARL. If the brain is affected by a lack of oxygen, experiencing unusually high pressure, or altered by specific medications or drugs, it may malfunction, causing the pupils to act abnormally. They may become dilated (bigger than normal), constricted (smaller than normal), unequal in size, or slow to react to light.
MVC: Motor vehicle crash. An older term is MVA — motor vehicle accident. The word "accident" implies that nothing could have been done to avoid the event; most crashes are, in fact, preventable. Other trauma mechanisms can also have shorthand documentation, such as auto-ped (automobile versus pedestrian).
L, R, +, –: Left, right, positive findings, negative findings. These symbols can be used as shorthand for common words.
