Record keeping and documentation for first aiders

Any first aider will know that documentation is incredibly important. There is no ‘set’ way to document a patient, however below is a suggested guide based around basic abbreviations used in the medical world. It might not always be appropriate for all patients, however certainly for more complicated patients it provides a useful framework that you can use.Paperwork

These abbreviations are universally recognised, so you don’t need to write them all out on your forms.

 PC: Presenting complaint – what is the problem? Why has the patient sought medical attention?

 HPC: History of Presenting Complaint – when did the problem start? Have you had it before? What events led up to the problem occurring?

 O/A: On Arrival – what did you find when you arrived at the scene (not always applicable)

 O/E: On Examination – what did you find when you examined / looked at the patient?

 PMH: Past (relevant) Medical History

 Meds: Medication (past and present)

 Allergies: Any known allergies?

 Imp: Your impression of the patient / problem – suspected diagnosis

 Tx: Specific treatment carried out by you

 Plan: What’s the plan for this patient? Handover? Transport?

Other common ‘shorthand’ abbreviations:

This is by no means comprehensive, but just guide to a few common abbreviations you may see on patient report forms.

Pt: Patient

LoC: loss of consciousness

DHx: Drug history

Ca: Cancer

IDDM: Insulin Dependent Diabetes Mellitus

NIDDM: Non-insulin Dependent Diabetes Mellitus

MoI: Mechanism of Injury

D&V: Diarrhea and vomiting

#: Fracture

?: Query / suspected

SoB: Short of breath

DiB: Difficulty in breathing

AF: Atrial Fibrillation

MI: Myocardial Infarction

COPD: Chronic Obstructive Pulmonary Disease

CVA: Cerebrovascular Accident

NFR: Not for resuscitation

UTI: Urinary tract infection

VF: Ventricular fibrillation

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5 Responses

  1. theshaynee says:

    We were taught extensively about this in technical training.
    I love medical terminology and always have. It’s handy to know the abbreviations and meanings.
    We also learned about charting and signs and symptoms.
    Great post! Definitely sharing.

  2. cpefley says:

    Thank you for this list! I knew a few of those abbreviations, but most of them I did not. Great to know shorthand, because it makes it so much easier to jot down in an emergency. Definitely a great list to memorize!

  3. TPhoenix says:

    This makes plenty of sense for any medically aiding individual to know. I am glad you provided these medical abbreviations. I had zero clue about most of them, so I ended up learning something today.

  4. chellebaeby says:

    I am a nurse and documentation is stressed in nursing school. It is hard to remember events in your head, especially in an emergency situation. I always try to remember the most important things and if I can write down the rest as soon as possible. It is useful when the EMTs arrive on the scene. You can quickly give a report.

  5. katews says:

    Good list and totally important for anyone doing first aid to be familiar with.

    Is fracture no longer Fx?

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