Tuesday, May 7, 2024

CME: So I’m Reading Your Note, Can You Explain a Few Abbreviations to Me?

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CME: So I’m Reading Your Note, Can You Explain a Few Abbreviations to Me?

Excuse me?  Hey!  Sorry to bother you.  Did you write this note?  You did?  Okay, good!  See, I’m trying to read your note, which is quite sloppy might I add, and you use a lot of abbreviations.  A LOT.  Would you mind, if it wouldn’t be too much trouble, if you could answer a few questions for me?

With your help, I can figure out what kind of note this is. Thank you so much!

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Lumbar Puncture LP Spinal Tap

Two Examples of Amazingly Subpar Lumbar Puncture Procedure Notes

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Amazingly Subpar Lumbar Puncture Procedure Note #1 Procedure: This is Spinal Tap. Date/Time: Optional. Indication: Infectious Diseases said it was a good idea. Resident: Dr. Kyle Richter, PGY-1. Attending: Yes. A time-out was completed to...