FLORIDA HOSPITAL
Heartland Division-
Management of Information Policy/Procedure Manual
CATEGORY: Management of Information
SUBJECT: Abbreviations
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.
Ø 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.
ü 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.
ü If the prescription order is found illegible, the prescription order is verified with the prescriber before it is filled.
ü 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.
ü The term “units” should be spelled out rather than abbreviated as “U”
ü 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 Expression / Intended Meaning / Misinterpretation / Correction / Suggested AbbreviationMS
MSO4
MgSO4 / Confusion for one another. Can mean morphine sulfate or magnesium sulfate. / Write “morphine sulfate” or “magnesium sulfate” / NONE
U or u / unit / Read as a zero (0) or a four (4), causing a 10‑fold overdose or greater (4U seen as “40” or 4u seen as 44”). / “Unit” has no acceptable abbreviation. Use “unit.” / “unit” has no acceptable abbreviation- write out UNIT
IU / (for international unit) / Mistaken as IV (intravenous) or 10 (ten) / Write “International Unit” / NONE
Trailing Zero
Leading Zero Missing / 1 mg (X.O mg)
Lack of leading Zero (.X mg) / Decimal point is missed / Do not use terminal zeros for doses expressed in whole numbers. / Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point (0.X mg)
Q.D.,
Q.O.D / Latin abbreviation for once daily and 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” and “every other day” / NONE
μg / Microgram / Mistaken for mg (milligrams) resulting in one thousand-fold dosing over dose / Write “mcg”
T.I.W. / Three times weekly / Mistaken for three times a day or twice weekly resulting in an overdose / Write 3 times weekly or three times weekly / NONE
A.S.
A.D.
A.U. / Latin abbreviation for left, right, or both ears / Mistaken for OS, OD, and OU, etc. / Write left ear, right ear, or both ears; left eye, right, eye or both eyes. / NONE
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