Medical Abbreviations

The use of medical abbreviations has been used since the development of medicine and is a longstanding practice. They are thought to save time and space when writing medical records. Additionally, they are cost effective and can be customized. While many healthcare facilities have gone to electronic records, the practice of handwritten records still exists, thus the continuance of handwritten medical abbreviations.  

Paper records are prone to errors. Illegible writing causes confusion and at times, a delay in care due to a need for follow up with the author for clarification; especially when it comes to medication orders and dispensing. Many abbreviations may have more than one meaning and the staff interpreting the record may not be familiar with the abbreviation being used.  

In 2005 The Joint Commission, an enterprise that accredits and certifies healthcare organizations, adopted a list that is forbidden to be used by Joint Commission accredited facilities. Below is the list along with an explanation of the potential problem.  

*DO NOT USE POTENTIAL PROBLEM USE INSTEAD  
U, u Mistaken for “0” (zero), the number “4” (four) or cc Write “unit” 
IU (international unit) Mistaken for IV (intravenous) or the number ten (10) Write “International Unit” 
Q.D., QD, q.d., qd (daily)   Mistaken for each other  Write ‘daily” 
Q.O. D., QOD, q.o.d., qod Period after the Q mistaken for “I” and the “O” mistaken for “I” Write “every other day” 
Trailing zero (X.o mg) (Applies to medication orders) Decimal point is missed  Write X mg Write 0.X mg 
MS     MSO4 and MgSo4 Can mean Morphine Sulfate or Magnesium Sulfate   Confused for one another  Write “morphine sulfate” Write “magnesium sulfate” 

 2020 The Joint Commission Fact Sheet 

*List does not apply to preprogrammed health information technology systems.  

The Joint Commission has made a recommendation to not sure the symbols for “greater than” or “less than” as they may be interpreted for the letter L or the number 7. The symbol for at (@) is discouraged because it may be misinterpreted as the number 2. Instead, providers should write out the words, “greater than”, “less than” or “at” as they appropriately apply in the chart.  

Misinterpretation of abbreviations may result in patient harm to include death. R&G nurses are skilled at reading handwritten records and recognized when a contributing error has occurred. If you are an attorney and need help with your case, please contact R&G at 1-888-486-2245. 

Historical Perspective for a Successful Legal Nurse Consulting Firm

R&G Staff 
January 2021 

R&G Medical Consultants, now R&G Medical Legal Solutions, was founded in February 1992 by Rosie Oldham, BS, RN, LNCC. Her background in nursing administration, risk management and quality improvement were extremely valuable in the startup of the firm. 

R&G’s first cases were personal injury and in December 1992, the firm began working on product liability cases (resulting in completion of over 750 cases). This led to staff expansion and rapid company growth. During this project R&G   implemented total quality management procedures. Peer review of work products led to a successful 100% deficiency free submission of claims. From 1994 to 1996, R&G processed over 450 toxic tort cases (water contamination) for the defendants.  In 1997, R&G began focusing on complex medical malpractice and personal injury cases.  

Fast forward to 2021. Use of and incorporation of technology is the foundation of R&G’s continued success to managing large scale projects.  Incorporation of nurse project directors and non-nurse project managers free clients from the administrative burden of coordinating many logistical areas of mass tort. Record retrieval combined with customizable nurse work products allow for one stop shopping for clients.  

Foundational services such as nurse work products that range from in-depth, pertinent verbatim to summaries of care remain a staple.  Hybrid products, such as a combination of pertinent verbatim of key events, combined with summaries of general that capture events in an efficient, cost effective manner are now offered.    

A new service related to radiology films, will be launched in the near future.  Clients will be able to view, manage, and share radiology data online in lieu of tracking and managing CDs.  Key features of the service include cinematographic (CINE) views, digital measuring tools and panning.  

All services at R&G are customizable to fit the needs of each client.  No project is too big or small.  If interested in R&G services please call Catherine Beasley, MS, BSN, LNCC at 623-566-3333 or email cbeasley@rngmedical.com .   

Legal Nurse Consultants… Put them into action

A legal nurse consultant (LNC) is a subject matter authority on nursing and healthcare matters much like how an attorney is an expert in legal matters. They are state licensed, detail-oriented healthcare professionals, working on behalf of the litigation team.  

Legal nurse consultants apply their knowledge, education, and clinical training to medical legal cases. Supreme is their ability to interpret medical records. Using their nursing knowledge, LNCs can quickly evaluate medical records and distill them into comprehensive summaries, or chronologies. Their attorney clients can then quickly read, understand, and put them into action. 

The primary role of LNCs involves the identifying, analyzing, and evaluating medical records while providing their professional opinions regarding health issues in medical legal cases. This field of study is composed of evaluating the standards of care, causality, and other medically related issues through the examination of medical records, healthcare literature, and legal documents. Their expertise extends to multiple topics, including: long-term care, medical malpractice, personal injury, worker’s compensation, and mass-tort litigation.  

Legal nurse consultants will also be able to establish a chronology or summary of medical records, and prepare evidence for trial. Additionally, they act as a liaison between the attorney, the healthcare provider, and medical experts. In brief, legal nurse consultation is a valuable asset to the litigation team. 

R&G Medical Legal Solutions has an extensive team of certified legal nurse consultants, that are available around-the-clock, 24-7, to assist you with anything you need. We are agile, in that we can scale up or scale down the project workload to adapt to your needs as they change. Please give us a call today to see how legal nurse consulting at R&G can solve problems for you, dial 1-623-566-3333 or send us an email: rngrfp@rngmedical.com