Abbreviations and Acronyms in Clinical Documentation ...



Abbreviations and Acronyms in Clinical Documentation – Mental Health, Alcohol and Other DrugsA guide for mental health, alcohol and other drugs service clinicians to promote patient safety and improve the quality of patient recordsDocument titleAbbreviations and Acronyms in Clinical Documentation – Mental Health, Alcohol and Other DrugsContact detailsDepartment of HealthApproved bySenior Director Mental Health Alcohol and Other DrugsDate approved15/10/2020Document review15/10/2024TRM numberContents TOC \o "1-4" \h \z \u 1. Purpose PAGEREF _Toc54334481 \h 32. Responsibilities PAGEREF _Toc54334482 \h 33. All documentation PAGEREF _Toc54334483 \h 34. Medication prescribing and documentation PAGEREF _Toc54334484 \h 35. Principles for consistent prescribing terminology PAGEREF _Toc54334485 \h 36. List of approved abbreviations and acronyms PAGEREF _Toc54334486 \h 46.1. Names of roles PAGEREF _Toc54334487 \h 46.2. Locations, teams and programs PAGEREF _Toc54334488 \h 56.3. Key non-government organisations PAGEREF _Toc54334489 \h 66.4. Measures and symbols PAGEREF _Toc54334490 \h 66.5. Observations PAGEREF _Toc54334491 \h 76.6. Pathology Investigations PAGEREF _Toc54334492 \h 76.7. Pharmacology Administration PAGEREF _Toc54334493 \h 96.8. Substances PAGEREF _Toc54334494 \h 96.9. AOD Withdrawal Scales PAGEREF _Toc54334495 \h 106.10. Familial abbreviations PAGEREF _Toc54334496 \h 106.11. Miscellaneous and noting PAGEREF _Toc54334497 \h 106.12. Diseases/conditions PAGEREF _Toc54334498 \h 12PurposeThe purpose of this document is to:Ensure mental health (MH) and alcohol and other drug (AOD) clinicians maintain a consistent and broad understanding of accepted abbreviations utilised within MH and AOD services;Ensure Health records and documentation can be accurately interpreted over time by those giving and receiving information and instruction regarding patient care; Minimise the risks associated with the use of abbreviations, symbols, abbreviated medication dose designations and acronyms used in the clinical health setting; Promote patient safety; andEliminate the use of unsafe abbreviations.ResponsibilitiesAll clinicians have a responsibility to ensure they comply with this policy. Managers are required to ensure that all clinicians are aware of and apply this policy. All documentationOnly approved abbreviations, acronyms and symbols can be used in all clinical documentation processes. Use plain English, do not use jargon. Write in full – avoid using abbreviations wherever possible. Note capital letters, lower case lettering, full stops and slashes, as these are important in the interpretation of the abbreviations.All written documentation, including prescriptions must be written in black ink. Medication prescribing and documentationThe use of inconsistent, ambiguous or non-standard abbreviations and terminology in the prescribing of medicines is a major cause of medication errors. Standardisation of terminology and abbreviations has been identified as an important strategy in reducing these errors. Australian standardised terminology, abbreviations and symbols have been developed. Please refer to the Recommendations for terminology, abbreviations and symbols used in medicines documentation, prepared by the Australian Commission on Safety and Quality in Healthcare and adopted by the Australian Health Ministers Advisory Council. Principles for consistent prescribing terminologyAll written documentation, including prescriptions MUST be written in black ink. Use plain English – avoid jargon. Write in full – avoid using abbreviations wherever possible, including Latin abbreviations Print all text – especially drug names.Use generic drug names. Exception may be made for combination products, but only if the trade name adequately identifies the medication being prescribed. Exception may also be made where significant bioavailability issues between brands exists eg. cyclosporine.Write drug names in full. NEVER abbreviate ANY drug name. Some examples of unacceptable drug name abbreviations are: G-CSF (use filgrastim or pegfilgrastim), 5-FU (use fluorouracil), EPO (use epoetin). For slow release, controlled release, or other modified release products, the description used in the trade name to denote the release characteristics should be included with the generic drug name, for example tramadol SR, carbamazepine CR, metformin XR.For multi-drug protocols, prescribe each drug in full and do not use acronyms, for example do not prescribe chemotherapy as ‘CHOP’. Prescribe each drug separately.Do not use chemical names/symbols. Eg. HCl (hydrochloric acid or hydrochloride) may be mistaken for KCl (potassium chloride).Use words or Hindu-Arabic numbers i.e. 1, 2, 3 etc. Do not use roman numerals i.e. ii for two, iii for three etc.Use metric units such as gram or mLUse a leading zero in front of a decimal point for a dose less than 1 e.g. use 0.5 not .5.Do not use trailing zeros e.g. use 5 not 5.0For oral liquid preparations, express dose in weight as well as volume e.g. for morphine oral solution 5mg/mL prescribe the dose in mg and confirm the volume in brackets 10mg (2mL).For oral liquid preparations, express dose in weight as well as volume e.g. for morphine oral solution 5mg/mL prescribe the dose in mg and confirm the volume in brackets 10mg (2mL).Express dosage frequency unambiguously e.g. use ‘three times a week’ not ‘three times weekly’ as the latter could be confused as ‘every three weeks’.Avoid fractions e.g. 1/7 could be interpreted as ‘for one day’, ‘once daily’, ‘for one week’, or ‘once weekly’; 1/2 could be interpreted as ‘half’ or as ‘one to two’.Do not use symbolsAvoid acronyms or abbreviations for medical terms and procedure names on orders or prescriptions e.g. avoid EBM meaning ‘expressed breast milk’.List of approved abbreviations and acronymsNames of rolesAcronymsFull formAMHWAboriginal Mental Health WorkerAPPApproved Psychiatric PractitionerCNClinical NurseCVCommunity VisitorBDRBanned Drinker RegisterCAGConsumer Advisory GroupCNCClinical Nurse ConsultantCNEClinical Nurse EducatorCNSClinical Nurse SpecialistCNMClinical Nurse ManagerDMHPDesignated Mental Health PractitionerDMODistrict Medical OfficerDrDoctorENEnrolled NurseGPGeneral PractitionerNPNurse PractitionerOTOccupational Therapist/TherapyRMOResident Medical OfficerRNRegistered NurseSACSenior Assessment ClinicianSTCSenior Treatment ClinicianSWSocial WorkerRegRegistrar (Medical Officer)Locations, teams and programsAcronymsFull formADSCAAlcohol and other Drug Services Central AustraliaAODAlcohol and Other DrugsASHAlice Springs HospitalBMHSBarkly Mental Health ServiceCVPCommunity Visitor ProgramCAHSCentral Australia Health ServiceDRMHTDarwin Remote Mental Health TeamEAMHTEast Arnhem Mental Health TeamEDEmergency DepartmentGDHGove District HospitalIWASIntegrated Withdrawal and Assessment ServiceJRUJoan Ridley UnitKDHKatherine District HospitalKMHTKatherine Mental Health TeamMHATMental Health Access TeamMH CAHSMental Health Central Australia Health ServiceOPDOutpatient DepartmentOPPOpiate Pharmacotherapy ProgramRAPURapid Admission and Planning UnitRDHRoyal Darwin HospitalTCDHTennant Creek District HospitalTEHSTop End Health ServiceTEMHSTop End Mental Health ServiceTEAMhealthTop End Association for Mental HealthYIPYouth Inpatient ProgramKey non-government organisationsAcronymsFull formAADANTAssociation of Alcohol and Other Drugs Agencies Northern Territory AIMSAboriginal and Islander Medical ServiceAMSANTAboriginal Medical Services Alliance Northern TerritoryBRADAAGBarkly Region Alcohol and Drug Abuse Advisory GroupCAAAPUCentral Australian Aboriginal Alcohol Programs UnitCAACCentral Australian Aboriginal CongressCAAPSCouncil for Aboriginal Alcohol Program ServicesDASADrug and Alcohol Services AustraliaFORWAARDFoundation of Rehabilitation With Aboriginal Alcohol Related DifficultiesMeasures and symbolsAcronymsFull formoCDegree celsiuscc / cm3 / cm3Cubic centimetrecmCentimetregGramkcalKilocaloriekgKilogramkJKilojouleLLitre mMetremgMilligram mJMegajoulemLMillilitremmMillimetremmolMillimolepHHydrogen ion concentrationNote: Microgram is not to be abbreviated; Units (eg Insulin) are not to be abbreviatedObservationsAcronymsFull formBALBlood alcohol levelBPBlood pressureCWMSColour, warmth, movement, sensation HRHeart rateHtHeightNeuro ObsNeurological observationsObsObservationsO2satsOxygen saturationSGSpecific gravityTPRTemperature, pulse, respirationsU/AUrinalysisWtWeightPathology InvestigationsAcronymsFull formAlbAlbuminALPAlkaline PhosphtaseALT Alanine Amino Transferaseanti-HBsHepatitis B antibody; postanti-HBe Hepatitis B e antibodyBALBlood alcohol levelBeta HCGHuman chorionic gonadotropinBili BilirubinBSLBlood sugar levelBGLBlood glucose levelClChlorideCMPCalcium magnesium and phosphateCreatCreatinineCRPC-reactive proteinCSFCerebrospinal fluidESRErythrocyte sedimentation rateeGFREstimated glomerular filtration rateEtOHAlcoholFBCFull blood countFBEFull blood examinationGTTGlucose Tolerance TestGGT Glutamyl TranspeptidaseHAV IgM Hepatitis A (IgM)HbHaemoglobinHbA1cGlycosylated haemoglobinHBsAb Hepatitis B antibody; postHBV sAgHepatitis B antigen HBsAg Hepatitis B antigen HBV eAgHepatitis B e antigen.HBeAg Hepatitis B e antigen.HBV eAbHepatitis B e antibodyHCO3BicarbonateHCV Hepatitis C antibodyHDLHigh density lipidsHIVHuman Immunodeficiency Virus (antibody)HIV VL Human immunodeficiency viral loadKPotassiumLDLLow density lipidsLFT Liver Function TestLi LithiumLipidsCholesterol LDL, HDL and TrigsNaSodiumNCNeutrophil countProtProteinRBC Red blood corpuscles (No nucleus so they’re not cells)TB or AFB Acid fast bacilli culture/Examination for mycobacterium tuberculosisTFT Thyroid function tests TrigsTriglyceridesTPTotal proteinTSH Thyroid stimulating hormoneUDSUrine drug screenUECUrea, electrolytes and creatinineUPROT Urinary proteinWBCWhite blood cellWCC White cell countPharmacology AdministrationAcronymsFull formBDTwice a daydailyOne time per dayIMIntramuscular (injection)IVIntravenous (injection/infusion)maneMorningmiddayMiddaymixMixturenebNebulisernocteNightO or POOral (per os)prnAs necessary (pro re nata)QIDFour times per day (quater in die)SubCutSubcutaneousSubLingSublingualStatImmediately (statim)TDSThree times per day (ter in die)SubstancesAcronymsFull formATSAmphetamine type stimulantBZDBenzodiazepinesEtOHAlcohol (ethanol)NRTNicotine replacement therapyOPOpiates/opioidsTHCMarijuana/cannabisVSAVolatile substance abuseVSUVolatile substance useAOD Withdrawal ScalesAcronymsFull formAWS Alcohol Withdrawal Scale (Remote Health)CIWA-arClinical Institute Withdrawal Assessment of Alcohol Scale – revised COWSClinical Opiate Withdrawal ScaleFamilial abbreviationsAcronymsFull formBroBrotherDauDaughterFaFatherMoMotherSisSister SonSon Miscellaneous and notingAcronymsFull formA/AAs aboveADLActivities of daily livingASAPAs soon as possibleAWOLAbsent without leaveAxAssessmentBIBABrought in by AmbulanceBIBPBrought in by PoliceBSL/BGLBlood sugar level/Blood glucose levelC/AClinical assessmentCPRCardiopulmonary resuscitationCQIContinuous quality improvementd/cDischargeDOADead on arrivalDDxDifferential diagnosisDNADid not attend DOBDate of birthDVDomestic violenceDVODomestic violence orderDxDiagnosisECGElectrocardiogramFASFoetal alcohol syndromeFASDFoetal alcohol spectrum disorderFBCFluid balance chartFHxFamily historyFVFamily violenceHRNHealth/hospital registration numberH/VHome visitHxHistoryLAMALeft against medical adviceMedsMedicationsMVAMotor vehicle accidentN/ANot applicableNADNo abnormalities detectedNBMNil by mouthNCPNursing Care PlanNESBNon-English speaking backgroundNFANo fixed abode/addessNFRNot for resuscitationNOKNext of kinO/AOn admissionO/EOn examinationPHxPast historyR/VReviewRxTreatment/TherapyTCTelephone callTOLTook own leaveDiseases/conditionsAcronymsFull formABIAcquired brain injuryARBIAlcohol required brain injuryAIDS Acquired Immune Deficiency SyndromeALD Alcoholic Liver DiseaseARFAcute renal failureBIBrain injuryCCFCongestive cardiac failureCOAD Chronic Obstructive Airways DiseaseDT’s Delirium tremensD & VDiarrhoea and vomitingIHD Ischaemic Heart DiseaseLOC Loss of consciousness(A) MI (Acute) myocardial infarctionMRSA Multi-resistant staphylococcus AureusRDSRespiratory Distress SyndromePE Pulmonary embolismPVD Peripheral Vascular DiseaseSARSSudden Acute Respiratory SyndromeSTDSexually transmitted diseaseT1DMDiabetes Mellitus type one (Do not use Roman numerals)T2DM Diabetes Mellitus type two (Do not use Roman numerals)TB TuberculosisTIA Transient ischaemic attackTBITraumatic brain injuryURTIUpper respiratory tract infectionUTI Urinary tract infectionQuality AssuranceMethodResponsibilityImplementation Document will be placed on PGC and the internet and relevant staff and relevant non-government organisations will be advised of this via email. New NT Health employees will be advised of this document upon commencementSenior Policy Officer - Quality and Business SystemsUnit ManagersReviewThis document will be reviewed within 4 years, or as required.Senior Director Mental Health Alcohol and Other Drugs DoHEvaluationEvaluation of document will be informal and ongoing Senior Director Mental Health Alcohol and Other Drugs DoHComplianceIncidents associated with errors owing to use of non-approved or approved abbreviations must be reported and managed through the RiskMan systemUnit Managers ................
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