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Joint Commission mandates that in order to be accredited as an acute care facility, hospital should use uniform data whenever possible
synonymous w/any short expression that is perceived to represent a longer word/group of words abbreviation
abbreviation formed from initial letters of each of successive words/major parts of compound term, or of selected letter of word/phrase that is pronounced as a word acronym
abbreviation formed from initial letter of each of successive words/major parts of compound term or of selected letter of word/phrase that is not pronounces as a word but by each letter initialism
abbreviation that results in shortened form of a single word rather than initial letter of series of words brief form
abbreviations, acronyms, & brief forms should only be used for internationally recognized & accepted units of measure & for widely recognized terms & symbols
unless abbreviation, acronym, or brief form is so widely used that it has become a term in its own right use expanded form 1st, followed by its abbreviated form in parentheses
will require facilities to be contemplative & careful about abbreviations they deem acceptable interoperability btwn disparate healthcare systems
do not use abbreviation when term is __ in full dictated
units of measure can be abbreviated even if they are dictated in full
ADHI does not recommend abbreviation of __ __ unless facility preference dosage instructions
when universally recognized abbreviations are used within medical record they do not require expansion, even 1st time referenced in a report
abbreviation must be __ __ if used in admission, discharge, preoperative, or postoperative diagnosis; consultative conclusion; or operative title written out
always transcribe diagnosis __ __ & include dictated abbreviation in parentheses immediately following in full
dictation of non-disease-entity abbreviations accompanies diagnostic & procedure statements they may be used if dictated
if rare disease-entity abbreviations are better known by their abbreviations than by full delineation it is best to leave it abbreviated
when abbreviated diagnosis, conclusion, or operative title is dictated & abbreviation used is not familiar/has multiple meanings should be transcribed as dictated and flagged
metric units of measure that accompany numeric values &/or are part of virgule constructions should be abbreviated
do not use __ with abbreviated unit of measure periods
use the abbreviated unit of measure only when __ __ precedes unit of measure numeric quantity
__ __ common nonmetric units of measure to express weight, depth, distance, height, length, & widths, except in tables spell out
do not abbreviate __ __ units of measure, except in tables most nonmetric
do not abbreviate nonmetric units in virgule constructions except when expression combines metric unit with most nonmetric unit
some businesses are readily recognized by abbreviations/acronyms, & may be referred to by same if dictated & if there is reasonable assurance business will be accurately identified by reader
most abbreviated forms for business entities use __ __ all capitals
most abbreviated forms for business entities do not __ __ use periods
when determining capitalization & punctuation of business entities, always be guided by entity's designated abbreviated form
abbreviate state & territory names when they are preceded by city, state, or territory name
do not abbreviate names of states, countries, or similar units within reports when they stand alone
use abbreviations in state names in a(n) address on letters/envelopes
avoid use of contractions in record, even if dictated, except in direct quotations
when possible, extend abbreviations that contain __, particularly when they represent slang/coined terms contractions
when using contractions in direct quote, take care to place __ correctly apostrophe
sentence may begin with __ abbreviation, or such abbreviated forms may be __ dictated; expanded
avoid separating a(n) __ from its associated unit of measure or accompanying abbreviations, keep them together at line breaks numeral
when automatic word wrapping brings unit of measure to 2nd line carry numeral with it
when expanding dictated abbreviation in diagnosis/operative title sections of report, place abbreviation __ __ following expanded expression in parentheses
if a term is dictated in full there is no need to include abbreviation reference
capitalize all letter of most acronyms, but when they are expanded do not capitalize words from which they are formed unless they are proper names
do not capitalize abbreviations from __ terms Latin
use __ within or at end of Latin abbreviations, but its also acceptable to drop them periods
use lowercase abbreviations w/periods for Latin __ that are related to doses/dosages abbreviations
avoid using all capitals for Latin abbreviations related to doses/dosages because they emphasize abbreviation rather than drug name
avoid lowercase Latin abbreviations related to doses/dosages without periods because some may be misread without words
do not capitalize brief form unless extended form is routinely capitalized
__ capitalize most units of measure or their abbreviations don't
always capitalize genus name abbreviations when they are accompanied by species name
use of __ after genus name abbreviation is acceptable, but ADHI/AMA recommend dropping it period
do not abbreviate species name even if genus name is abbreviated
do not use periods within/at end of most abbreviations, including acronyms, abbreviated units of measure, & brief forms
use period at end of abbreviated nonmetric units measure if they may be misread without period (only in virgule constructions & tables)
do not use periods with __ academic degrees & credentials abbreviated
use periods in lowercase __ abbreviations derived from Latin terms drug-related
do not use periods w/abbreviated personal & courtesy titles unless it is known that person in question prefers inclusion of period(s)
use lowercase s without apostrophe to form plural of capitalized abbreviation, acronym, or brief form
use 's to form plural of lowercase abbreviations
use 's to form plural of __ abbreviations single-letter
add 's to most abbreviations/acronyms to show possession
US Pharmacopoeia (USP), Institute for Safe Medication Practices (ISMP), US FDA, & National Coordinating Council for Medication Error Reporting & Prevention (NCCMERP) are organizations involved in identifying & preventing problems/errors in medication orders from abbreviations
published list of dangerous abbreviations & dose designations as reported to USP-ISMP Medication Errors Reporting Program US Pharmacopoeia (USP)
ADHI promotes adoption of dangerous abbreviations & dose designations listing from USP-ISMP Medication Errors Reporting Program
almost 50% of __ __ standards directly related to patient safety in some way Joint Commission
designed to improve safety measures in identified key areas of patient management & care; July 2002 Joint Commission approved 6 National Patient Safety Goals (NPSGs)
improve effectiveness of communication among caregivers Goal 2 of 2004 Joint Commission, program-specific NPSGs
standardize a list of abbreviations, acronyms, & symbols that are not to be used throughout the organization 2nd directive of Goal 2 of 2004 Joint Commission, program-specific NPSGs
ADHI recommends learning & memorizing __ abbreviations considered dangerous & __ those abbreviations appropriately when encountering them in dictation all; editing
rule for omitting trailing zeros only pertains to __ __, not to measurements outside of this domain medication dosages
when author chooses to dictate trailing zero on any other measurement (i.e. describe mass, lesion, wound, etc.) this should be transcribed as dictated
use of trailing zero after decimal can be __ __ on part of physician/dictator to ensure reflection of exact/precise measurement vs approx measurement intentional inclusion
transcription should not assume a(n) __ measurement where none is indicated, but trailing zero should only be included if __ precise; dictated
using U for unit is prohibited, although acceptable to use when referring to certain types of insulin
rule for changing cc to mL only pertains to liquid volume
cubic centimeter references to mass (i.e. measuring organs, tissues, & specimens of solid volume) should be transcribed as cc
when cc is use to describe other non-liquid volumes, such as gas, this should be retained & not changed to mL
in the case(s) of erroneously dictated dangerous abbreviations, Joint Commission recognizes the Author of a document as person who dictates documentation to be transcribed
according to Joint Commission, if "do not use" term is used in dictation & dictation is clear, that term should be transcribed as spoken; not translated or edited into its presumed meaning
ADHI asserts that despite recommendation by Joint Commission about erroneously dictated dangerous abbreviations MTs are still deployed in risk management role to identify & correct erroneously dictated dangerous abbreviations & pointing it out to the facility; defer to facility policy on how to handle this issue
ADHI recommends MTs __ corrections recommended for full ISMP list of dangerous abbreviations adopt
fundamentally it is __ that determined adoption & evolution of newly coined terms/abbreviations derived from those terms usage
you should always consult __ __ when in doubt about up-to-date abbreviations or acronyms appropriate references
abbreviation meaning also known as; use lower case letters w/periods to distinguish from other forms a.k.a.
lowercase forms, with periods, preferred; formal publications use small capitals a.m., AM, p.m., PM
abbreviations w/phrase such as in the morning, in the evening, tonight, o'clock do not use
abbreviation for beats per minute bpm/BPM
abbreviation for blood pressure BP
write out - & + because -/+ may be easily overlooked when writing out blood types
placed in patient's chart when patient/family indicates no emergency resuscitative measures are to be employed DNR
courtesy title for doctors; used only for earned doctorates, not honorary doctorates; use of period acceptable, but strong trend towards omission Dr/Dr.
use Dr not Doctor in __ unless it is directly to more than one doctor; do not use in plural form salutations
do not use Dr/Doctor when __ are given credentials
use __ abbreviations w/periods for Latin abbreviations that are related to dose/dosage lowercase
avoid using all capitals, relating to dose/dosage, because they emphasize __ and not __ __ abbreviation; drug name
avoid lowercase abbreviations, relating to dose/dosage, __ __ because some may be misread as words without periods
when inserting a numeral (as in q.4 h.) ADHI, on the advise of ISMP, inserted a(n) __ after the numeral so that it is more easily read space
correct abbreviation for: before food a.c.
correct abbreviation for: twice a day b.i.d.
correct abbreviation for: drops (spell out) gtt.
correct abbreviation for: nothing by mouth n.p.o.
correct abbreviation for: do not repeat n.r.
correct abbreviation for: after food p.c.
correct abbreviation for: by mouth p.o.
correct abbreviation for: as needed p.r.n.
correct abbreviation for: every 4 hours q.4 h.
correct abbreviation for: every hour q.h.
correct abbreviation for: four times a day q.i.d.
correct abbreviation for: three times a day t.i.d.
correct abbreviation for: as directed u.d.
acceptable brief forms for examination when dictated, except as heading exam
correct abbreviation for: junior/senior in names; use of periods/commas still acceptable but strong trend towards omission Jr/Jr. & Sr/Sr.
correct abbreviation for: Doctor of Medicine; preferred style w/out periods; if periods used do not separate w/space w/in abbreviation MD/M.D.
correct abbreviation for: milliequivalent; use with numerals; do not use periods; do not add s for plural mEq
correct abbreviation for: milligrams percent; equivalent to milligrams per deciliter (mg/dL) which is preferred nomenclature, but transcribe as dictated; do not use periods; do not space btwn symbols mg%
correct abbreviation for: millimeters of mercury; use w/pressure readings (BP, tourniquet pressure, etc.); need not use if not dictated mmHg
correct abbreviation for: subcutaneous or subcuticular subcu
when you are sure which term is intended, and subcu is dictated, spell subcu or subcut
when abbreviating subcutaneous or subcuticular do not use _ _ because _ can be mistaken for medication sub q; q
can serve as abbreviated forms of words/phrases in language symbols
the trend is to avoid symbols in health data capture, in order to promote interoperability & electronic exchange
correct symbol for: and; use w/certain single-letter abbreviations separated by the word and; so not space before/after symbol; do not use symbols in operative titles/diagnoses ampersand (&)
correct symbol for expressing angles in orthopedics; write out the word or use the symbol degrees (º)
correct symbol for expressing angles in imaging studies or temperature expressions (º)
if (º) symbol not available you should write out degree(s)
correct symbol for: expressing inches in tables, as a space-saving device (")
do not use to indicate the same, instead repeat word/phrase; so not use as symbol for inches, outside of usage in tables ditto marks (")
do not use these 2 symbols, except in table & mathematical expressions (÷) & (=)
the word greater is over used, instead a better choice of words might be more, longer, or over
many times dictating physician will read chart when dictating, and will use words that go with the __ symbol, when that may not be best translation of symbol shorthand
2 symbols often mistaken for their opposite sign in meaning, & ISMP advises against their use (>) & (<)
spell out English translation when word stands alone, do not capitalize English translations; when it is part of an extended term, spell it out/use abbreviation according to preferred form Greek letters
in extended terms, use of hyphen after Greek letter is __, but __ is not used after English translation optional; hyphen
correct symbol for expressing minus or minus sign; write out the word if you are not certain the symbol will be noticeable or clear; also use symbol to indicate below-zero tempuratures (-)
do not use except in tables or special applications, i.e. blood nomenclature; avoid because usage may cause reader to overlook it negative sign (-)
use the symbol/abbreviation for number before apartment, suite, or room number only, when words apartment, suite, or room number are not used No. or (#)
do not use No. or (#) before house number in street address
do not use (#) to represent the words pound(s)
percent is a single word; do not use abbreviation __ except in table pct.
percent is a single word; use symbol after a numeral; do not space btwn numeral & symbol (%)
use __ for number preceding (%); when a number is written out at beginning of sentence, __ __ percent numerals; write out
do not use __ sign without a numeral plus
in laboratory/technical readings, use the symbol unless it will not be noticeable/clear plus, plus sign (+)
use only w/numerals; use lowercase in expression of area & volume, as multiplication symbol, & when it takes place of word times; used to express dimensions (x)
use only w/numerals; use capital to express magnification (X)
when word times is dictated it can be translated as for, it should be transcribed as for rather than times or (x)
when words times is dictated and means number of times a thing was done, it can be transcribed as (x)
Created by: lfrancois