Poll: "Do Not Use List" of abbreviations

[soontobe_RN]

what do you think about the "do not use list" of abbreviations implemented by the joint commision in 2004?

information can be found at the address below.

http://jcsearch.jcaho.org/cgi-bin/msmfind.exe?query_encoding=utf-8&cfgname=mssfind.cfg&query=do+not+use+list&and_on=y&no_dl=x

once you get to this page click on:

2006 npsgs - goal 2 faqs

thank you for voting :)

[LegalBeagle]

for those of you out there who may find yourselves resistant to these changes, let me give you a little of my background. i work as a nurse consultant in a law firm - we work to defend doctors, hospitals, and yes, nurses from suits raised against them. sometimes, unfortunately, we lose. sometimes it is clearly a case of negligence. but other times, its not necessarily so.

if you think your charting doesn't matter, or that no one will read it, think long and hard, and think again! all over the country there are people like me, working in law firms, who when litigation comes up, read your notes very carefully. we go over every detail with a fine toothed comb.

if we represent the defense (doctor, nurse, etc) we read carefully to be sure all protocols are followed and that proper procedure was followed.

if you represent the alleged wronged party, you are also looking over notes, charts, summaries and all those forms with the tiny checkboxes in them, looking for inconsistencies, unchecked items that leave questions, documentation that does not make sense, inconsistent orders, etc.

charting is important - hopefully no one in this forum will find out just how important when they find themselves sitting in front of a bank of lawyers in deposition, or in court facing a judge and jury, and being asked to read someone's scrawl or even their own. i've seen docs and nurses shrug their shoulders at their own notes because they could not remember them or just could not read them. if anything makes an impression on a jury, that does.

if it's important enough to write down, it's important enough to write down legibly and with due care and attention to the whole picture.

just a few words of caution from someone who knows....

what do you think about the "do not use list" of abbreviations implemented by the joint commision in 2004?

information can be found at the address below.

http://jcsearch.jcaho.org/cgi-bin/msmfind.exe?query_encoding=utf-8&cfgname=mssfind.cfg&query=do+not+use+list&and_on=y&no_dl=x

once you get to this page click on:

2006 npsgs - goal 2 faqs

thank you for voting :)

[soontobe_RN]

For those of you out there who may find yourselves resistant to these changes, let me give you a little of my background. I work as a nurse consultant in a law firm - we work to defend doctors, hospitals, and yes, nurses from suits raised against them. Sometimes, unfortunately, we lose. Sometimes it is clearly a case of negligence. But other times, its not necessarily so.

If you think your charting doesn't matter, or that no one will read it, think long and hard, and think again! All over the country there are people like me, working in law firms, who when litigation comes up, read your notes very carefully. We go over every detail with a fine toothed comb.

If we represent the defense (doctor, nurse, etc) we read carefully to be sure all protocols are followed and that proper procedure was followed.

If you represent the alleged wronged party, you are also looking over notes, charts, summaries and all those forms with the tiny checkboxes in them, looking for inconsistencies, unchecked items that leave questions, documentation that does not make sense, inconsistent orders, etc.

Charting IS important - hopefully no one in this forum will find out just how important when they find themselves sitting in front of a bank of lawyers in deposition, or in court facing a judge and jury, and being asked to read someone's scrawl or even their own. I've seen docs and nurses shrug their shoulders at their own notes because they could not remember them or just could not read them. If anything makes an impression on a jury, THAT does.

If it's important enough to write down, it's important enough to write down legibly and with due care and attention to the whole picture.

Just a few words of caution from someone who knows....

I agree with you completely. The one thing I have learned is that anything used for documentation can be used in the court of law, so, it is considered a legal document. My question for you is, have you ever had a court case b/c a doctor or nurse used an abbreviation that was on the "Do not use list"? I am just curious, b/c I have heard from others that if someone has been in the field for a long time it is difficult to remember or get in the habit of not using these prohibited abbreviations.

Thanks for the advice!! :)

[HuggyPuglet]

I agree with you completely. The one thing I have learned is that anything used for documentation can be used in the court of law, so, it is considered a legal document. My question for you is, have you ever had a court case b/c a doctor or nurse used an abbreviation that was on the "Do not use list"? I am just curious, b/c I have heard from others that if someone has been in the field for a long time it is difficult to remember or get in the habit of not using these prohibited abbreviations.

Thanks for the advice!! :)

No, I have not directly seen any case just because of a doctor or nurse using the prohibited abbreviations. I have seen many problems with illegible or confusing abbreviations, notes, or conflicting information on, say, an admission form (LOC, or no LOC for instance, on the same triage form). In the defense of doctors, nurses, etc., this type of situation makes the defense case more difficult than it need be and it could be prevented. The problem I see is that staff is oftentimes overworked and rushing, and that is where many of the problems stem from.

I would imagine, though, that there may have been, or will be, cases coming up if an abbreviation was used that should not have been, and the use of that abbreviation caused the misinterpretation of information that led to the patient being harmed. It's only a matter of time.

[Tweety, BSN, RN]

I got busted yesterday for writing an order "MS 10 mg IV".....boy it's hard to break years of habits. But I'm trying. The frustrating thing is I was saying to myself "gotta remember not to write MS" and I wrote MS anyway.

[traumahawk99]

we've got to have a standardized language. i'm all for it.

[soontobe_RN]

I got busted yesterday for writing an order "MS 10 mg IV".....boy it's hard to break years of habits. But I'm trying. The frustrating thing is I was saying to myself "gotta remember not to write MS" and I wrote MS anyway.

I am I guess what you would call a Med Aid or Med Tech until I become an RN. Just this weekend, when I was assisting a clt with their med, I noticed on the MAR that this past week, everyone has been using cc instead of ml, even our nurses. And we have a sheet by the med carts that says what abbreviations to use and not use. So, I can see where it is really easy to use one of the prohibited abbreviations until we get the hang of it. I made sure to put ml and then let the Head nurse know, so that se could do whatever it is that she needed to do about it. I know there is someone that comes out, I think once a week, to check over our MARs and any other med documentation. What happens from that point, I don't know.

[julie978]

Oh yes, the do not use abbreviations....I think computer entry would solve the whole thing easily. No messy handwriting to guess at and the computer could be programmed to reject the do not use abbreviations. my facility is years away from that technology though....!

[soontobe_RN]

Oh yes, the do not use abbreviations....I think computer entry would solve the whole thing easily. No messy handwriting to guess at and the computer could be programmed to reject the do not use abbreviations. my facility is years away from that technology though....!

I agree. Computer entry would help a lot, but lately, there has been a problem with the computers, as well. I know a big concern is the medication info on computers is causing many med errors. From what I read in the AJN (June 05 issue), many times patients will have screen after screen of meds and the patients name is only available on the first screen, so, of course this is causing nurses to give meds to the wrong patients. Another issue was that when a patient is moved to another room, the computer still has that pt in the previous room and again, the wrong pt recieving the medication and the correct pt missing a dose. As I said, this article was in the American Journal of Nursing June 05 issue. It expained many other problems that are occuring due to computers. Check it out if you get a chance. It was pretty interesting and disturbing at the same time.

[dinkymouse]

It is hard to tell from some people's writing the difference between some letters. I know I have to decipher a lot of things that if abbreviations weren't used I would get right away.