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Old 04-11-2011
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Question Can we say "CTA B" in patient note?

For breath sounds, is the abbreviation CTA B accepted? Or do we have to write out Clear To Auscultation Bilaterally?

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Old 04-11-2011
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Default You can do it if the case is not respiratory

The term CTA is fairly common in US practice. You can say something like lungs; CTA. They will for sure know what you mean by that.

However, if the case is respiratory or if complete chest exam is required then it's better to type something like the following:
Chest: Clear symmetrical breath sounds bilaterally, No wheezes, rales, or rhonchi; tactile fremitus normal; N percussion note.

The reason why you should be writing this whole info is to let them know that you were aware of the importance of the chest examination and that you have actually done it, even though there were no signs to report.

Note that if you haven't done these, it's better not to fake them, i.e., if you have not tested the fremitus or the percussion, don't mention them in the PN.
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Old 04-11-2011
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Ummm, I am not sure if that is necessary. I can tell you from my own experience that I used acronyms like CTAB, RRR, Abdomen nt nd, fairly generously in my exam, even when writing the physical for the system relevant to the case and it worked out just fine. These are pretty commonly used in US hospitals and as most of the notes are evaluated by practicing physicians, they atleast don't mind it if not prefer it.
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