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

John Furst

JOHN FURST is an experienced emergency medical technician and qualified first aid and CPR instructor. John is passionate about first aid and believes everyone should have the skills and confidence to take action in an emergency situation.

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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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