Abbreviation Usage
I. POLICY STATEMENT:
For the purpose of promoting quality and patient safety, unapproved abbreviations will not be acceptable for use.
II. PURPOSE:
It is the purpose of this policy to define the abbreviation clarification process to assure orders are written in a safe and acceptable manner. Orders with unapproved abbreviations without clarification are not to be processed.
III. DEFINITIONS:
Unapproved Abbreviations: A list of medical abbreviations that have been adopted as unacceptable by the organization because of their potential for patient harm. (See Addendum “A”).
IV. SCOPE:
This policy applies to all practitioners, allied health professionals and staff who communicate medical information.
V. PROCEDURE:
A. When processing an order, the nurse and/or unit secretary will review for unapproved abbreviations.
B. If an unapproved abbreviation is noted, the unit secretary will notify the nurse.
C. If the practitioner is still present, the order will be clarified and rewritten.
D. If the practitioner is not present and the order is unclear or cannot be clearly interpreted, then the practitioner is to be called for verbal order clarification.
E. If the order is clear, the nurse may rewrite the order with correct abbreviation or word and a clarification form will be placed on the chart. This rewrite will only clarify the abbreviation.
F. The practitioner will sign the clarification at the next available time.
G. If there are questions about any other medical abbreviations click on the “Medical Abbreviations” link available from the Huguley Intranet Home page,
VI. REPLACE POLICY:
II – 1010 Abbreviation Usage
VII. APPROVAL COMMITTEE AND DATE:
Patient Care Governance, e-vote: 23 January, 2012
VIII. ADDENDUM:
Addendum “A” - “Do Not Use” Abbreviations
“ADDENDUM A”
Huguley Memorial Medical Center
DO NOT USE
ABBREVIATIONS
|DO NOT USE |USE |
|U (for unit) |“unit” |
|IU (for international unit) |“international unit” |
|Q.D. |“daily” |
|Q.O.D. |“every other day” |
|Trailing Zero (X.0 mg) |“X mg” |
|Lack of Leading Zero (.X mg) |“0.X mg” |
|MS | |
| |“morphine sulfate or |
| |magnesium sulfate” |
|MSO4 | |
|MgSO4 | |
Reviewed 12/2011
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