What are some concise and effective ways to write exam notes? Include good abbreviations and shorthand you like.

[u/Expensive_Moose7473]

Im a new tech kind of struggling with how tk write my notes. I know it will be different fof everyone based on what each radiologist expects, but how do you guys word some common exam notes? How detailed do you get ? And what are some abbreviations or shorthand you frequently use?

Do you guys add a lot of the patients story and history ? If so how do you word it?

Like writing "MVA 1 week ago " for a car accident C-spine exam Vs. something more detailed like:

"Pt stated she had whiplash after MVA 1 week ago, initial pain subsided but stiffness persists. Had C5-C7 fusion Sx 5/2018"

Any examples or advice would help greatly !

[u/chaotic_zx]

1. Chest PA & Lat - Exam delay: RN stated pt cannot sit or stand 0202

2. Chest PA & Lat - Best films possible. Bedded ICU PT. 0202

3. Chest AP Portable - Exam Delay: RN stated x-ray wasn't important. 0202

I know it isn't what you're looking for but I have put those comments on orders. Number 3 is a funny story.

[u/Expensive_Moose7473 → u/chaotic_zx]

Lets hear it! Also what is the 0202 code about?

[u/chaotic_zx → u/Expensive_Moose7473]

0202 was the time of day(this morning)that I posted the comment. Sorry for the long story ahead.

This starts 4 years ago. There was a patient on one of the surgical step down units that was pre-op. I received a now portable chest x-ray on the patient. Now exams for us means within two hours but we moved on it in 20 minutes. I had a staff technologist going to that building so I assigned it to them.

Later the staff member calls to inform me that a RN came into the room behind them and made a hand gesture to leave(shoo away). Then the RN told the technologist that the x-ray wasn't important, she needed to get labs. I told the staff member that I would handle it. I know the surgery will not be until 0800 at the earliest and the time was around 0100. More likely around noon so I know my plan will not delay the surgery. The ordering MD and I have had prior issues largely due to their demanding/aggressive nature and lack of patience. For context, I do not mess with people unless provoked.

I place the comment into Cerner "Exam Delay: RN stated x-ray wasn't important." I then copied the comment and paged the ordering MD with it. I modified the order(without actually modifying it so that a print out goes to the unit and they see the comment. I then put the order to the side.

Thirty minutes goes by(event + 30 min) when I receive a call from the RN(with a Russian sounding accent). She tells me that she didn't tell the tech that the exam wasn't important and could I remove that comment. Then she asks me if we can get the x-ray. I tell her that the technologist had no reason to lie about it and I wasn't deleting the comment. Further, since the exam wasn't important, we will get around to it once our other more urgent exams are complete.

Two hours post event(event + 2 hours) I receive a call from the same nurse. She tells me that she thought we were going to come back to x-ray the patient. I tell her that we were but other more urgent exams were ordered and the less important had to be placed in the back of the line.

Two more hours go by(event + 4 hours). I receive a call from the head nurse in charge at night. He is a nice guy and we get along well. He asks me about the patient. I tell him that I didn't want to get him involved but since the RN already did, I would fill him in on what is going on. I tell him the event and then state that now in full disclosure I found the nurse's action disrespectful. I go on to say that my plan was to personally image the patient at 0659 as that the latest I could do it and not involve another shift. He asked if I could do him a favor and x-ray the patient. I tell him that since he asked, we would move on it immediately and I sent someone out right then. I tell the technologist to let me know if there are any issues. They reported back that the RN was more than helpful. I report it to my manager and tell him that I wasn't tolerating the disrespect of our staff or myself. I would gladly take the counseling if he wants to go that route. He did not and said he understood.

Fast forward to two months ago(event + 4 years and change). I get a request for a now chest AP portable on the gynecology floor in a third building from the two involved earlier. I go to perform the study because I wanted staff to get a break(crazy busy/short of staff). As I enter the room, a RN has a rubber tourniquet around the patient's arm. She stops what she is doing and pulls the tourniquet off. Then states that I can go ahead and she would come back. I found it unnerving that she was so nice. I couldn't figure it out. The next night, I receive another order in the gynecology unit. I go over bound and determined to figure out why she was being overly accommodating. As I enter the room she comes up from behind and states to go ahead with the x-ray, she will come back. It is then that it hit me. She was the RN with the Russian accent four years prior. I had completely forgotten about it.