Use of Acronyms in Chart Notes

Kristen Bensel

Networker
Messages
48
Location
Pilot rock, OR
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0
Good Afternoon!
I am wondering if anyone out there can help me. I work in a clinic that has a unique range of providers, we have A&D Counselors, Mental Health LCSW's, MD's, PA's, ARNP's, Dental and Pharmacy. Because we have such a range of providers, we have many different styles of notes that we have to wade through when coding the encounters.
I understand that there are lists of do not use acronyms due to potential for medication dosage issues, but is there documentation anywhere that states the types of acronyms that are acceptable? Or if it is frowned upon to use acronyms that are for non medically related things (ex. S.O.) or different types of therapies that might be used to help treat the patient... Isn't there a rule that things like that should be written out so that there is no chance of confusion of what is happening if a provider of a different specialty doesn't have to use Google to decipher the chart note?
Any help or advice is greatly appreciated and Thanks in advance!
 

Daniel Rowden

Networker
Messages
55
Location
Gainesville, FL
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0
As far as I'm aware there is only the Do Not Use list. I've worked with hospitals that expand on the list to include more things that can be commonly confused (i.e. AKI can be Acute Kidney injury or insufficiency). I've also seen ones where they have lists of acceptable abbreviations.

It is best practice however to make the note as non-cryptic as possible. You want someone to be able to read the note easily. It would be best to establish a policy about what are acceptable and what are not acceptable abbreviations and to have a clear definition list of acceptable ones.
 
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