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Be Cautious of Abbreviations and Acronyms in the Medical Record

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  • March 21, 2018
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Be Cautious of Abbreviations and Acronyms in the Medical Record

Acronyms and abbreviations are acceptable in the medical record if they are commonly recognized. If a practice uses terminology that is not industry standard, it must maintain a list of the abbreviations with definitions and how they are used, and should submit this documentation anytime an audit is done.
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. The do not use list should be included on each provider’s list:

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”
(International Unit)
Mistaken for IV
(intravenous) or the number 10 (ten)
“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
MSO4 and MgSO4
Can mean morphine sulfate or magnesium sulfate Confused for one another Write “morphine sulfate”
Write “magnesium sulfate”

Source: The Joint Commission

John Verhovshek
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About Has 577 Posts

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.

No Responses to “Be Cautious of Abbreviations and Acronyms in the Medical Record”

  1. T. Thivierge MHA ,CBCS, CPC says:

    Oh My! There are many more medical acronyms listed which can cause confusion. Providers really need to spell it out just a bit more in their documentation. Just saying because no one needs confusion these days!