Wiki Abbreviations Guidelines

[mrosbun]

Hi,

I work in Compliance and we are having a discussion in regards to the use of abbreviations in the medical note. Of course, being in the medical field we all know what the common abbreviations are, but what if someone is reading the note and they don't have the medical background. We are struggling to find any guidelines in regards to abbreviations. Is there any guidelines out there that state what abbreviations can be used and cannot be? The Joint Commission has a short list in regards to medication terms.

Thank you in advance for any help or advice you can give.

Ruby

 

[Chelle-Lynn]

There is no "official" list of what abbreviations are acceptable which ones are not. It is recommended that the facility develop a list of appropriate abbreviations and their definitions so that auditors and coders can refer to when review medical records.

The Joint Commission has published a standard for the appropriate use of abbreviations as well as a minimum list of dangerous abbreviations, symbols, etc. This can be located at

www.jointcommission.org/facts_about_do_not_use_list/

 

[TThivierge]

Medical Abbreviations

Hi,

I work in Compliance and we are having a discussion in regards to the use of abbreviations in the medical note. Of course, being in the medical field we all know what the common abbreviations are, but what if someone is reading the note and they don't have the medical background. We are struggling to find any guidelines in regards to abbreviations. Is there any guidelines out there that state what abbreviations can be used and cannot be? The Joint Commission has a short list in regards to medication terms.

Thank you in advance for any help or advice you can give.

Ruby

Hi
I suggest the medical coder needs to Goggle on the internet the medical abbreviation. This will help immensely. I audit medical coding and come across doppelgangers and medical abbreviations may not be familiar. In order to get the meaning of the documents doing this really helps. Each medical specialty may have own set of abbreviations plus there are disease have same abbreviations too. As example the medical abbreviation PE can define Physical Exam, Pulmonary Embolism or Pleural Effusion it depends on surrounding meanings in the physician's notations.
I hope this helps you
Lady T

 

[Agilbert3]

[ As example the medical abbreviation PE can define Physical Exam, Pulmonary Embolism or Pleural Effusion it depends on surrounding meanings in the physician's notations.
I hope this helps you
Lady T[/QUOTE]

I wouldn't interpret an abbreviation based on the surrounding data in the note. If the abbreviation definition is unclear, the provider should be queried for clarification. But I work for a clinic that has no standardized abbreviation list, so otherwise I'd reference that first.

 

[KellyLR]

Medical Acronyms made up or not

Hello All,

I work as an IP Auditor. When I worked in OP, I had a provider who would use their own made up acronyms. Drove me nuts. No amount of negotiating a compromise worked with this provider (who sat on boards...) to get the provider to use acceptable acronyms when documenting in the medical record. So I decided to skin the cat a different way. It was decided by the group's policy that if a provider uses an acronym or description of a procedure that does not meet accepted guidelines for use, the provider who uses the acronym would give a definition of what the acronym meant and it would be added to a list for all to have access to including external business entities who may be onsite to perform health care or auditing. Within a month, that provider started using the appropriate acronyms because of all the inquiries the provider did not want to be bothered with. Also there was several medical acronym books available in the coding office. Just be sure to mark those so they don't walk off!

Hope this helps