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.