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.
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.
LoC: loss of consciousness
DHx: Drug history
IDDM: Insulin Dependent Diabetes Mellitus
NIDDM: Non-insulin Dependent Diabetes Mellitus
MoI: Mechanism of Injury
D&V: Diarrhea and vomiting
?: 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