Abbreviations

abbreviations are acceptable when a facility has a policy that specifically lists the ones that are acceptable for employees to use in their documentation. over the years, some of the facilities i've worked in have had either very long extensive lists or short ones. they will sometimes include abbreviations that are unique to their facility that no one else in the world uses. depends on the facility and who got behind the policy that got put into effect. usually it's a combination of people from medical records, nursing and medicine departments that get on these comittees and get these things put into effect.

and, of course, as you've discovered, jcaho has gotten involved with their do not use list. have you seen the ismp's list of error prone abbreviations? it is here: http://www.ismp.org/tools/errorproneabbreviations.pdf

When my home health agency got on the JCAHO Do Not Use list bandwagon, they sent out copies of their list of accepted abbreviations to each employee with the Do Not List terms annotated at the end. We also got a couple of updated versions. We were also told to basically stop using abbreviations in our day to day charting. I started writing everything out, because I didn't want to get called in to rewrite my notes. That's how I solved the problem. Unfortunately, nobody started telling the MDs to start writing out their orders completely and to stop using terms like QOD.

It leads me to wonder if other facilities have such a list of approved abbreviations. Anyone care to comment on this?

If they do, they will be in the nursing policy and procedure manual under documentation or part of the medical records policy and procedure manual.