Abbreviations used in medical record documentation can be confusing and lead to patient safety errors. Please fully type out all words when entering your documentation in the patient record. See examples of unacceptable abbreviations and how they can be confused, as well as correct documentation.
Can you read this progress note?
Impression: 16 mom with history of atd admitted with wheezing and stridor with concern for infectious process, croup v bronchiolitis. Plan: FEM/GI: PO ad lib, will SLIV 2/2 great poi + reflexive UOP. Resp: SORA. Neck pain film not concerning for obvious stenosis v obstruction...
This is an actual documented statement in a Children's progress note. What does it mean? If you have to guess what it means, could you make a mistake? Grappling with abbreviations is not only a problem for caregivers but parents who receive discharge instructions that have abbreviations. For a non-clinical person, abbreviations are the equivalent of a foreign language. Even common abbreviations such as QID or PFEM can be dangerous and need to be spelled out in the patient record.
Recent audits of medical records revealed that some staff make up abbreviations while others are using 'texting' abbreviations. Some staff type "asthma pfem" in the comment field in the education PowerForm and when it transfers to the patient family discharge form, the family does not understand what it means.
The following types of abbreviations cannot be understood by all staff and would be challenged by regulatory agencies such as the Joint Commission or in a court of law. The use of any abbreviation is dangerous and the following abbreviations may never be used because they have led to unsafe patient care:
DO NOT use List of Abbreviations
|Unacceptable/Do Not Use||Result||Acceptable|
|U (unit)||Mistaken of "0" (zero), "cc", or the number "4" (four)||Write "unit"|
|IU (International Unit)||Mistaken for IV (intravenous) or the number 10 (ten)||Write "International Unit"|
|Q.D., QD, q.d., qd||Mistaken for each other||Write "daily"|
|Q.O.D., QOD, q.o.d., qod||Period after the Q and O mistaken for "I"||Write "Every other day"|
|Trailing Zero (eg. -Ativan X.0mg)||Decimal point is missed||Write X mg (eg-Ativan 1mg)|
|Lack of leading zero (eg-Digoxin .125mg)||Decimal point is missed||Write 0.X mg (eg- Digoxin 0.125mg)|
|MS||Mistaken for morphine sulfate or magnesium sulfate||Write "morphine sulfate or magnesium sulfate"|
|MSO4 and MgSO4||Mistaken for morphine sulfate or magnesium sulfate||Write "morphine sulfate or magnesium sulfate"|
|Μg||Mistaken for mg (milligrams)||Write "mcg" or "micrograms"|
|Abbreviations for Chemotherapy Drugs||Mistaken for similar drugs||Write out drug name-exception is limited to Vincristine derivatives and PEG-asparaginase|