36C25019R0051-025.pdf

MEDICAL CENTER POLICY 011-027

December 30, 2015

Solicitation 36C25019R0051 Attachment D.3 - Abbreviations and Symbols

LOUIS STOKES CLEVELAND

VA MEDICAL CENTER

10701 East Boulevard Cleveland, OH 44106

ABBREVIATIONS AND SYMBOLS

1. PURPOSE. To advise clinicians on abbreviations and symbols which are not approved for use at the Louis Stokes Cleveland VA Medical Center.

2. POLICY. It is the policy of the Louis Stokes Cleveland Medical Center that a list of “do not use” abbreviations should be available to persons using the medical record. Final diagnosis and any complications in the discharge summary should be recorded without the use of symbols and abbreviations.

3. PROCEDURE

a. Proposed additions or deletions to the list of non-approved abbreviations should be forwarded to the Clinical Informatics Committee. The committee will recommend approval, disapproval or modification to the Medical Executive Council. The Medical Executive Council will recommend approval disapproval or modification to the Medical Center Director. Actions approved by the Medical Center Director will be made known to the persons using the medical record and incorporated in revisions on the “do not use” list.

b. The currently non- approved list is published as an attachment to this policy. It will be reviewed and revised when necessary on a regular basis. Approved changes (additions and deletions) will be made as needed.

c. The approved list should be available to all nursing stations and readily accessible to medical records personnel.

4. REFERENCE. The Joint Commission 2015

5. RESCISSION. All previous versions of Medical Center Policy 011-027 are rescinded. The next review date of this policy is December 30, 2018.

6. FOLLOW-UP RESPONSIBILITY. Chief of Staff.

//s//

SUSAN M. FUEHRER

Medical Center Director

Attachment

Solicitation 36C25019R0051 Attachment D.3 - Abbreviations and Symbols

MEDICAL CENTER POLICY 011-027

December 30, 2015

“Do Not Use” List of Abbreviations

Do Not Use Potential Problem Use Instead U,u (unit) Mistaken for “0” (zero), the number “4” (four) or “cc” Write “unit”

IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten)

Write “International Unit”

Q.D., QD, q.d., qd (daily)

Q.O.D., QOD, q.o.d, qod (every other day)

Mistaken for each other

Period after the Q mistaken for “I” and the “O” mistaken for “I”

Write “daily”

Write “every other day”

Trailing zero (X.O)*

Lack of leading zero (.Xmg) Decimal point is missed

Write X mg

Write 0.X mg

MS

Can mean morphine sulfate or magnesium sulfate

Write “morphine sulfate”

Write “magnesium sulfate”

MSO4 and MgSO4 Confused for one another

Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may be used in medication orders and other medication-related documentation.