Terminology Murder

I do break-relief in two ICU's. I read the charts of all those patients that I interact with, because I need to know what I'm dealing with for that one hour. This knowledge also allows me to contribute pertinent assessments, to assist the staff member I'm working with.

Bottom line; I read a lot of charts. I have decided to place some attention to the use of home-made Medical Terminology, those abbreviations that are not included on the standardized lists. Essentially, these are unique notations, understood by only that person who is doing the documentation. No nurse wants to end up in a court, arguing about what they were charting on that dark and stormy night; especially, when they were using unauthorized charting terminology.

Medical terminology?
We must agree,
To use the same terms
One, two, three,
To share information
Promotes understanding,
Or we’ll see you in court
And be more demanding.

GUOP, what is it?
Is it something you ate?
Might be GUacamole
On an Outdoor Plate,
And why chart it twice
How much urine amounted,
When it was entered on I & O
The running tally accounted?

Prop for sedation
Now what does that mean?,
A couple large pillows
In a stage-play scene?
When you charted it already
In the IV Drip roster,
In terms of documentation
You are an imposter.

S/W, makes me wonder
Did you mean Smith & Wesson?
What kind of a shot?
Please don’t keep us guessin’,
Because the family wants to know
How Billy-Bob died,
MDR completed, coninue poc
That’s what they cried.

Bld clt
Might have been talking
About me,
I belong to the bald cult
Check Facebook
You will see,
Might have meant
Blood culture
But it’s not our terminology,
Once again, your charting
Approaches pathology.

*  *  *  *  *  *  *  *  *  *  *

GUOP…………..good urine output
Prop…………….Propofol
S/W..................... spoke with
MDR completed, coninue poc…………(What did this convey?)
bld clt...................blood culture