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Managing Health Information: Use of Abbreviations, Acronyms, Symbols and Dose Designations - Understanding the Requirements

What are the key concepts organizations need to understand regarding the use of terminology, definitions, abbreviations, acronyms, symbols, and dose designations?  

Any examples are for illustrative purposes only

Intent
Standardized formats and terminology help ensure consistency in use and understanding of information when used by different individuals for various purposes.  Standardization also adds clarity to information when dealing with symbols and abbreviations that may have different meanings, depending on the context of use. Use of standardized formats for numeric values, such as medication dose designations and laboratory values add precision that reduces the risk of error when interpreting such information. The Joint Commission does not publish a list of approved abbreviations, etc.

Standardization
Organizations are expected to use standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations. Any reasonable approach to standardizing abbreviations, acronyms, symbols, etc. is acceptable.  Examples include: 
  • Standardized abbreviations developed by the individual organization. 
  • Use of a published reference source. However, if multiple abbreviations, symbols, or acronyms are used for the same term, the organization clarifies what will be acceptable. 
Organizations are not required to have a list of approved abbreviations, symbols, etc., however, the organization must be able to provide evidence of their approach to standardized entries.

Prohibited Abbreviations (*)
Organizations are required to follow a list of prohibited abbreviations, acronyms, symbols, and dose designations, which, at a minimum, includes the following:
U, u
IU
Q.D., QD, q.d., qd
Q.O.D., QOD, q.o.d, qod
Trailing zero (X.0 mg)
Lack of leading zero (.X mg)
MS
MSO4
MgSO4

The prohibited list applies to all orders, preprinted forms, and medication-related documentation. Medication-related documentation can be either handwritten or electronic. Organizations may also wish to review other sources that have identified additional error-prone abbreviations, such as those published by the Institute for Safe Medication Practices. 

Use of a trailing zero
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.

* NOTE: Prohibited abbreviations that are hard-coded into electronic health records by the software vendor in a manner that prevents the organization from editing, is acceptable.  However, any user-defined or customizable fields/forms created by the organization must not include prohibited abbreviations, acronyms, etc. Medication labels that contain prohibited abbreviations from the manufacturer are acceptable. Organizations contemplating adding or upgrading CPOE/EMR systems should strive to eliminate prohibited abbreviations as well as acronyms, symbols and dose designations that may create risk from the software.


 
Last updated on September 07, 2021
Manual: Hospital and Hospital Clinics
Chapter: Information Management IM

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