Abbreviation, symbol, dangerious abbrevations, unapproved ...



VA HEALTH CARE SYSTEMSIOUX FALLS, SOUTH DAKOTACENTER CIRCULAR 00B-21 November 2013 MEDICAL CENTER APPROVED AND “DO NOT USE” ABBREVIATIONS I. PURPOSE To standardize abbreviations and symbols used in clinicaldocumentation at the Sioux Falls VA Health Care System(SFVAHCS) and restrict use of dangerous abbreviations to augment safety through clear and concise communication via the patients’ medical record.II.POLICYA.Only abbreviations approved in Jablonski’s dictionary of abbreviations and acronyms will be used in the SFVAHCSB.Abbreviations are not to be used in the recording of final diagnoses, operations, or procedural titles on the Discharge Summary.C. There is a separate list of dangerous abbreviations that should not be used for any reason in the medical record (see attachment A).DEFINITIONSNone.IV.RESPONSIBILITIESA.All Service Line Directors will ensure that facility employees entitled to make chart entries comply with this center circular.B.Handwritten orders and /or prescriptions that include any of the “Do Not Use” abbreviations that are received in the Pharmacy will not be filled. These orders will be returned to the ordering provider for appropriate completion. C.Identified instances of “Do Not Use” abbreviations should be brought to the attention of the Patient Safety Office via completing a patient incident report. V.PROCEDURESA.Jablonski’s Dictionary of Abbreviations and Acronyms (2009) is the official reference for the use of abbreviations and acronyms at the Sioux Falls VA Health Care System. (See Attachment B for information on how to access this reference).VI.OTHERNone.REFERENCESJablonski's dictionary of medical acronyms & abbreviations (1-4160-5899-0, 978-1-4160-5899-1), 6th ed. / Jablonski, Stanley. Saunders/Elsevier, 2009.The Joint Commission (TJC) current editionRESCISSIONS Center Circular No. 00B-21, dated April 2004.IX.FOLLOW-UP RESPONSIBILITYBusiness Office Manager Review Date: November 2016X.This Center Circular will remain in effect until rescinded.SANDRA L. HORSMANActing DirectorATTACHMENTS: Attachment A: Prohibited (Do Not Use) Abbreviations Attachment B: How to Access Jablonski’sINFORMATION: 00B-21, Medical Center Approved Abbreviation List, November 2013ORIGINATOR: Business Office ManagerREQUIRED CONCURRENCE:QM Coordinator Primary Care Specialty Medicine SL DirectorSurgical Specialty Care SL DirectorMental Health SL DirectorEC&R SL Director Chief Of StaffADPCS/Nurse Exec. KEY WORDS:AbbreviationSymbolDangerous abbreviationsUnapproved Do not useRESCISSIONS: Center Circular No. 00B-21 dated April 2004. 6.REVIEW DATE: November 2016Attachment A356235118745PROHIBITED (DO NOT USE) ABBREVIATIONS00PROHIBITED (DO NOT USE) ABBREVIATIONS37719009906000228600107950The abbreviations listed below have been frequently misinterpreted. Therefore they have been designated as “Dangerous” by National, Network and local experts.They are NOT approved for use at our facility.00The abbreviations listed below have been frequently misinterpreted. Therefore they have been designated as “Dangerous” by National, Network and local experts.They are NOT approved for use at our facility.AbbreviationPotential ProblemPreferred TermU, u (for unit) ?Mistaken for “0””zero”, the number “4” (four) or cc. Write "unit"IU (for international unit) ?Mistaken as IV (intravenous) or 10 (ten).Write "international unit"Q.D., QD, q.d., qd (daily)Q.O.D., QOD, q.o.d., qod (every other day) *?Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for "I". Write "daily" Write "every other day"Trailing zero (X.0 mg), Lack of leading zero (.X mg)Decimal point is missed.Write X mgWrite 0.X mg?MSMSO4MgSO4?Can mean morphine sulfate or magnesium sulfate. Confused for one another. Write "morphine sulfate"Write "magnesium sulfate"?069215*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. Exception: A "trailing zero" may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.00*Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. Exception: A "trailing zero" may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.2374904015740*“Units” must be used in place of “U” or “u” for handwritten orders and progress notes.“U” will be transitioned to the dangerous abbreviations list for electronic mediums only when BCMA is updated to accept the additional characters necessary to spell out “UNITS”.00*“Units” must be used in place of “U” or “u” for handwritten orders and progress notes.“U” will be transitioned to the dangerous abbreviations list for electronic mediums only when BCMA is updated to accept the additional characters necessary to spell out “UNITS”.5224780395986000Attachment C00APPROVED ABBREVIATIONS REFERENCEJablonski's dictionary of medical acronyms & abbreviations (1-4160-5899-0, 978-1-4160-5899-1), 6th ed. / Jablonski, Stanley. Saunders/Elsevier, 2009.00APPROVED ABBREVIATIONS REFERENCEJablonski's dictionary of medical acronyms & abbreviations (1-4160-5899-0, 978-1-4160-5899-1), 6th ed. / Jablonski, Stanley. Saunders/Elsevier, 2009. Attachment BAccessing Jablonski’s Dictionary of Medical Acronyms and Abbreviations Open Internet browser and go to the Sioux Falls VA Health Care System Home Page:Click on Sioux Falls VA Health Care System Medical Library (See red arrow)\-957580162242500-70993083375500Open Jablonski’s by clicking on link (see red arrow below)-38100099885500After clicking on Jablonski’s you will have access to the online dictionary of abbreviations and acronyms that appears like the following screen shot:2374904015740*“Units” must be used in place of “U” or “u” for handwritten orders and progress notes.“U” will be transitioned to the dangerous abbreviations list for electronic mediums only when BCMA is updated to accept the additional characters necessary to spell out “UNITS”.00*“Units” must be used in place of “U” or “u” for handwritten orders and progress notes.“U” will be transitioned to the dangerous abbreviations list for electronic mediums only when BCMA is updated to accept the additional characters necessary to spell out “UNITS”.5224780395986000 ................
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