Reading the Medical Chart: Making Sense of Doctor's Orders

Because of rising concerns regarding patient safety, doctors are now being trained to improve on their handwriting and spell out their orders. But due to time or training constraints, some still continue to use old methods of making orders. Here are a few tips for nurses to make sense of the medical chart and the orders in them:

Know the Medical Chart Format

Some hospitals use a different method of making patient notes, but majority of doctors use the SOAP format. Knowing the sections of the chart will help you deduce what the doctor is trying to do for the patient

• The “S” portion on subjective complaints refers to the symptoms that patient’s experience.
• The “O” portion on objective findings refers to results of physical examination or laboratories as noted by the doctor.
• The “A” portion is the assessment or the doctor’s working diagnosis for the patient.
• The “P” portion on plan refers to the doctor’s orders on next steps including further diagnostic tests, medications, procedures, and other instructions for carrying out.

Know the Common Abbreviations

Some items in the chart cannot be understood, not because of handwriting, but because doctors abbreviate terms or use old Latin medical phrases. The Institute of Safe Medication Practices summarized a list of commonly misunderstood medical orders that should be avoided (https://www.ismp.org/tools/errorproneabbreviations.pdf). But in case they are used, here are descriptions of the most common abbreviations seen in medical charts:

Frequency	od - once a day bid - twice a day tid - three times a day qid - four times a day hs - at bedtime prn - as needed q - every (ex: q15m is every 15 mins, qh is every hour) d/c - discontinue
Laterality	AD / OD - right ear / right eye AS / OS - left ear / left eye AU / OU - both ears / both eyes
Descriptions with “-x”	sx - symptoms dx - diagnostics, or diagnosis bx - biopsy tx - treatment rx - medicines px - patient
Other names	PED - pediatric patient AP - attending physician
Body parts	heent - head, eyes, ears, nose, throat (also eent, ent) csf - cerebrospinal fluid abd - abdomen GB - gallblader KUB - kidney, ureter, bladder ing – inquinal
Physical exam tests or questions	BP - blood pressure HR - heart rate RR - respiratory rate EBL - estimated blood loss I&O - input and output ROM - range of motion LMP - last menstrual period
Laboratory tests	CBC - complete blood count PC - platelet count UA - urinary exam SE - stool exam CXR - chest xray AFB smear - acid fast bacilli smear ABG - arterial blood gas C/S - culture and sensitivity ECG – electrocardiogram
Conditions	UTI - urinary tract infection A/URTI - acute/upper respiratory tract infection CAP - community acquired pneumonia CA - cancer CAD - coronary artery disease CHF - congestive heart failure FBO - foreign body obstruction R/O - rule out (means a probable diagnosis, not yet certain)
Procedures	AP - appendectomy BKA - below knee amputation CPR - cardiopulmonary resuscitation I&D - incision and drainage
Other instructions	CBR - complete bed rest NPO - nothing per orem BRP - bathroom privileges DNR - do not resuscitate PT - physical therapy isol - isolation protocol vo - verbal order

Know the common orders for a specific case

Sometimes you can deduce the order from context clues. If the patient is suffering from pneumonia, then most likely antibiotics are given three times a day. If a diabetic patient is admitted for surgery, then pre-operatives laboratories are commonly comprehensive. If a patient is in critical condition in the ICU, then most likely monitoring is as often as every 15 minutes. Experience can also show you a doctor’s common patterns in treating their patients.

Don’t be Afraid to Ask for Help

But if you really can’t really understand the doctor’s orders, always ask for help. You can approach co-nurses or the actual doctor to help you understand what they want you to carry out. Never carry out an order that you are unsure of because this can be both harmful to the patient and the careers of yourself, the doctor, and the hospital. For cases like these, it is best to be safe than sorry.

Posted in: Advance Nursing,Fundamental of Nursing