Abbreviations, Do Not Use



Purpose

In the interest of patient safety, Florida Hospital Heartland Division and it’s Medical Staff adopted an abbreviations policy that includes a list of “Do Not Use” acronyms, abbreviations and symbols to guide documentation and prevent misinterpretation of handwritten notes.

Policy

▪ All abbreviations written into the medical record must be used with extreme caution and should not be ambiguous and should be context-specific so that the reviewer / caregiver clearly understands it’s intended meaning.

▪ Any abbreviation that is ambiguous or the meaning is not clear, should be verified with the author, however, there is a special process below defined for orders in particular.

□ Medical Abbreviations - 11th Edition - Authored by Neil M Davis,

Has been approved as the abbreviation source book for Florida Hospital Heartland Division.

➢ Where there are more than one meaning for one abbreviation, the abbreviation to be used will be context driven.

▪ Compliance of appropriate and inappropriate use of abbreviations will be monitored during on-going record reviews.

✓ If an unacceptable abbreviation is used in an order, the order must be verified with the author making the entry. The order will be re-written and state “Clarification”. The corrected order must be placed in the patient’s permanent medical record.

▪ The occurrence is to be reported via Incident Report to the Risk Management Department.

▪ The Risk Management Department will assess and address if needed

▪ The Risk Management Department will give report of trended information to Health Information Management Director for reporting to Utilization Review Committee on an on-going basis.

▪ Non-Compliance will be reported to the Utilization Review Committee, which has the responsibility of the oversight of medical record content and processes.

▪ Abbreviations are dangerous when they are illegible and are misread, particularly in regard to medications. TAKE TIME TO WRITE CLEARLY.

✓ If the prescription order is found illegible, the prescription order is verified with the prescriber before it is filled.

✓ Always use space between drug name, dose and unit of measure.

▪ Abbreviations on the “ABBREVIATIONS – DO NOT USE” list should not be used.

▪ It is encouraged that medication names be spelled out completely and not abbreviated.

▪ Abbreviations should not be used on consent forms.

▪ Apothecary symbols, if used should be used with caution. Use the metric system (exception are the therapies that use standard units such as insulin and vitamins.

✓ The term “units” should be spelled out rather than abbreviated as “U”

✓ If the term “unit” is abbreviated as “U” in electronic form (typed manner which is clear) it will be acceptable.

▪ If you are not sure of the correct abbreviation, spell it out completely.

▪ Abbreviations and symbols used on the flow sheets should have the same meaning as on other forms.

See Attachment for the “DO NOT USE” List

Effective Date: 01/95

Revised Date: 08/96. 04/00; 04/03

Reviewed Date: 3/97; 01/06

ABBREVIATIONS – DO NOT USE

If any abbreviation on this list is on a pre-printed form and is clear of it’s meaning – then it will be permissible. However – NO abbreviation on this list will be permitted on handwritten documentation..

|Abbreviation/Dose |Intended Meaning |Misinterpretation |Correction | |

|Expression | | | |Suggested Abbreviation |

|MS | |Confusion for one another. Can mean morphine sulfate |Write “morphine sulfate” or |NONE |

|MSO4 | |or magnesium sulfate. |“magnesium sulfate” | |

|MgSO4 | | | | |

|U or u |unit |Read as a zero (0) or a four (4), causing a 10‑fold |“Unit” has no acceptable |“unit” has no acceptable |

| | |overdose or greater (4U seen as “40” or 4u seen as |abbreviation. Use “unit.” |abbreviation- write out UNIT |

| | |44”). | | |

|IU |(for international |Mistaken as IV (intravenous) or 10 (ten) |Write “International Unit” |NONE |

| |unit) | | | |

|Trailing Zero |1 mg (X.O mg) |Decimal point is missed |Do not use terminal zeros for |Never write a zero by itself |

| |Lack of leading Zero | |doses expressed in whole |after a decimal point (X mg),|

| |(.X mg) | |numbers. |and always use a zero before |

|Leading Zero | | | |a decimal point (0.X mg) |

|Missing | | | | |

|Q.D., |Latin abbreviation for|Mistaken for each other . The period after the Q can |Write “daily” and “every other |NONE |

|Q.O.D |once daily and every |be mistaken for an “I” and the “O” can be mistaken |day” | |

| |other day |for “I” | | |

|μg |Microgram |Mistaken for mg (milligrams) resulting in one | |Write “mcg” |

| | |thousand-fold dosing over dose | | |

|T.I.W. |Three times weekly |Mistaken for three times a day or twice weekly |Write 3 times weekly or three |NONE |

| | |resulting in an overdose |times weekly | |

|A.S. |Latin abbreviation for|Mistaken for OS, OD, and OU, etc. |Write left ear, right ear, or |NONE |

|A.D. |left, right, or both | |both ears; left eye, right, eye| |

|A.U. |ears | |or both eyes. | |

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