Shorthand

Pt biba following RTC. 3xPCW around R 4-5 IC spaces. ?# R NOF as S+R of limb and dec ROM. GCS 12. MEWS of 5 due to rr 22, pr 114 and systolic bp 98. 15l o2 via non-rebreathe, maintaining sats 89%. ECG done and shown to dr. IV morphine administered as per prescription chart. CXR, Abdo XR and Hip XR ordered. Pt a/w tx ESAU.


This patient was an absolute wreck, I was helping work on him. Later that shift I found this nursing note written by a charge nurse also working on that patient. I can understand everything written there but I feel nursing notes should be a little clearer. The translation is as follows -

Patient brought in by ambulance. Three penetrating chest wounds around the right fourth and fifth intercoastal spaces. Query fractured right neck of femor as there is shortening and rotation of the limb and decreased range of motion. Glasgow coma scale of 12. Modified Early Warning System score of 5 due to resp rate of 22, pulse rate of 114 and systolic blood pressure of 98mmol. Patient on 15 litres of Oxygen via non-rebreathe mask and maintaining oxygen saturation of 89%. Electrocardiograph done and shown to doctor. Intravenous morphine administered as per prescription chart. Chest X-Ray, Abdominal X-Ray and Hip X-Ray requested. Patient awaiting transfer to emergency surgical assessment unit.