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Abbreviations That Are Unacceptable For Medical Record Documentation

This policy outlines abbreviations that should not be used in medical record documentation at Aurora Health Care facilities to reduce errors. It provides a list of unacceptable abbreviations and their potential for misinterpretation, such as "U" being mistaken for units or mg. Facilities must have mechanisms to ensure compliance and prohibit these abbreviations in all orders, forms, and medication documentation, whether electronic or handwritten. Trailing zeros are only allowed for results displaying precision but not for medication orders.

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Najeha Macapanton Abduljabbar
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51 views2 pages

Abbreviations That Are Unacceptable For Medical Record Documentation

This policy outlines abbreviations that should not be used in medical record documentation at Aurora Health Care facilities to reduce errors. It provides a list of unacceptable abbreviations and their potential for misinterpretation, such as "U" being mistaken for units or mg. Facilities must have mechanisms to ensure compliance and prohibit these abbreviations in all orders, forms, and medication documentation, whether electronic or handwritten. Trailing zeros are only allowed for results displaying precision but not for medication orders.

Uploaded by

Najeha Macapanton Abduljabbar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Aurora Health Care System Administrative / Clinical Manual

POLICY NO: 147

Effective:
01/04

Revised:
07/04
12/05
04/06
12/11
1/13
ABBREVIATIONS THAT ARE UNACCEPTABLE FOR
MEDICAL RECORD DOCUMENTATION

I. Policy
The following abbreviations should not be used in hospital based medical record
documentation of any orders and any medication related documentation.

II. Scope
a. This policy applies to hospitals and hospital based clinics of Aurora Health Care, Inc.
and to the Aurora Visiting Nurse Association.

III. Procedure
a. Each site will have mechanisms in place to ensure compliance with the following
unacceptable abbreviation list.

List of Unacceptable Abbreviations


Unacceptable Abbreviation Potential Problem Preferred Term
U (for unit) Mistaken as zero, four or cc. Write “unit”
IU (for international unit) Mistaken as IV (intravenous) or 10 Write “international unit”
(ten)
Q.D. Mistaken for each other Write “daily” and “every
Q.O.D. The period after the Q can be mistaken other day”
(Latin abbreviation for once for an “I” and the “O” can be mistaken
daily and every other day) for an “I”.
Trailing zero (X.0mg) Decimal point is missed Never write a zero by
Lack of leading zero (.X mg) itself after a decimal point
(X mg), and always use a
zero before a decimal
point (0.X mg)
MS Confused for one another. Write “morphine sulfate”
MSO4 Can mean morphine sulfate or or “magnesium sulfate”
MgSO4 magnesium sulfate.
µg Mistaken for mg (milligrams) resulting Write “mcg”
(for microgram) in ten-fold dosing overdose

T.I.W Mistaken for three times a day or twice Write “3 times weekly” or
(for three times a week) weekly resulting in an overdose “Three times weekly”

A.S., A.D., A.U. Mistaken for each other Write: “Left ear,” “Right
(Latin abbreviation for left, (e.g., AS for OS, AD for OD, AU for ear” or “Both ears;” “Left
right, or both ears) OU, etc.) eye,” “Right eye,” or “Both
O.S., O.D., O.U. eyes.”
(Latin abbreviation for left,
right, or both eyes)

Abbreviations That Are Unacceptable For Medical Record Documentation Policy #147
Page 1
Aurora Health Care System Administrative / Clinical Manual

b. An abbreviation on the “List of Unacceptable Abbreviations” should not be used in


any of its forms. This includes upper or lower case or with or without periods.
c. The prohibited list applies to all orders, preprinted forms, and medication related
documentation. Medication documentation can be either handwritten or electronic.
d. A trailing zero may be used only when required to demonstrate the level of precision
of the value being reported, such as for laboratory results, imaging studies that report
the size of lesions, or catheter/tube sizes. It may not be used in medication orders or
other medication-related documentation.

References
1. The Joint Commission (2013) Comprehensive Accreditation Manual for Hospitals:
http://www.jointcommission.org/
2. Joint Commission Perspectives on Patient Safety; March 2005
3. Joint Commission Perspectives on Patient Safety; May 2005

Abbreviations That Are Unacceptable For Medical Record Documentation Policy #147
Page 2

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