Acronyms in the Medical Record: Dos and Don’ts
- By John Verhovshek
- In Audit
- January 27, 2015
- Comments Off on Acronyms in the Medical Record: Dos and Don’ts
Acronyms are acceptable in the medical record, as long as they are commonly recognized. When using abbreviations that are not industry standard, you should maintain a list of the abbreviations with definitions and how they are used, and submit the documentation anytime an audit is performed.
Because confusing abbreviations can create problems with patient care, the Joint Commission (JC) has published a standard for the appropriate use of abbreviations as well as a “minimum list” of dangerous abbreviations, acronyms, and symbols:
| Official “Do Not Use” List | ||
| Do Not Use | Potential Problem | Use Instead |
| U, u (unit) | Mistaken for “0” (zero), the number “4” (four) or “cc” | Write “unit” |
| IU (International Unit) | Mistaken for IV (intravenous) or the number 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 Period after the Q mistaken for “I” and the “O” 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 mg Write 0.X mg |
| MS MSO4 and MgSO4 |
Can mean morphine sulfate or magnesium sulfate Confused for one another | Write “morphine sulfate” Write “magnesium sulfate” |
Source: The Joint Commission, http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf
John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.
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