D.4 Do Not Use List.docx
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This is a Medical Center Policy (MCP) document establishing procedures for standardizing prohibited abbreviations, acronyms, and symbols at the Charles George VA Medical Center in Asheville, North Carolina, effective November 2022 and scheduled for recertification in November 2027. The policy applies to all orders, preprinted forms, and medication-related documentation, both handwritten and electronic, in compliance with Joint Commission standards. The document identifies a prohibit list of commonly misinterpreted abbreviations including Q.D./QOD (daily/every other day), U or u (unit), IU (international unit), trailing zeros in medication notations, and MS/MSO4/MgSO4 (morphine sulfate, magnesium sulfate, and other terms), with preferred actions specifying that staff write out complete terms instead of using abbreviations.
The policy establishes clear responsibilities for the Chief of Health Administration Services to oversee implementation and compliance. Pharmacy Services must verify any medication orders containing questionable abbreviations with the prescriber before filling and report infractions to the Chief of Staff and Chief of HIMS for noncompliance patterns. An electronic listing of prohibited abbreviations is available to all staff in CPRS (Computerized Patient Record System) through the Tools menu. Proposed additions or deletions to the abbreviation list must be submitted through respective service chiefs to the Medical Records Committee and Medical Executive Council. The Medical Records Committee is responsible for periodic review and updates, with staff training and compliance monitoring to ensure health records remain unambiguous and suitable for legal review.
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Text version
MEDICAL ABBREVIATIONS
MCP 637-136-46
November 2022 MCP 637-136-46
Charles George VA Medical Center Asheville, NC 28805 Signatory Authority:
Charles George VA Medical Center Executive Director Responsible Owner:
Chief of Health Administrative Services Rescinded Document:
MCM 637-136-46, Medical Abbreviations, dated May 6, 2019 Effective Date:
November 2022 Recertification Date:
November 2027
1. POLICY
This medical center policy (MCP) establishes procedures for standardizing the unapproved abbreviations, acronyms, and symbols throughout the Charles George VAMC. The ‘Prohibit’ list applies to all orders, preprinted forms, and medication-related documentation. Medication-related documentation can be either handwritten or electronic.
2. JUSTIFICATION
Joint Commission IM.02.02.01 states the facility will follow its list of prohibited abbreviations, acronyms, symbols, and dose designations. The MCP establishes this list.
3. RESPONSIBILITIES
Chief, Health Administration Service. The Chief, Health Administration Service (HAS) is responsible for the contents of this memorandum.
4. ACTION
a. Identify and eliminate the abbreviations, acronyms and symbols as identified by Joint Commission as prohibited from use. Health Records are permanent documents subject to legal review and must, therefore, be without ambiguity in interpretation.
b. Providers should avoid the use of abbreviations for drug names and dosage requirements for any orders.
c. CPRS templates will not contain abbreviations without first identifying the abbreviation. For example, Post Traumatic Stress Disorder (PTSD).
d. An electronic listing of ‘prohibited’ symbols and abbreviations is available to all staff that makes entries in the medical record and others who use patient records in the course of their official duties. This listing can be found in CPRS. NOTE: When in CPRS, go to the Tools menu bar, click on Unapproved Abbreviations, then open the document.
e. Abbreviations, acronyms and symbols identified as “Prohibits” apply to preprinted forms, orders and medication related documentation within the health record.
5. PROHIBIT LIST OF ABBREVIATIONS
| Abbreviation |
| Potential Problem |
| Preferred Action |
| 1. |
| Q.D., QD, q.d., qd (daily) |
Q.O.D., QOD, q.o.d., qod (every other day)
| Mistaken for each other. The period after the Q can be mistaken for an “I” and the “O” can be mistaken for “I”. |
| Write “daily” and “every other day” |
| 2. |
| U or u(unit) |
| Mistaken as “0” (zero), the number “4” (four) or “cc.” |
| Write “unit” |
| 3. |
| IU (international unit) |
| Mistaken as IV (intravenous) or the number “10” (ten) |
| Write “international unit” |
| 4. |
| Trailing zero |
(X.0 mg) (Note: Prohibited only for medication-related notations).
Lack of leading zero (.X mg)
| Decimal point is missed |
| Never write a zero by itself after a decimal point (X mg), and always use a zero before a decimal point. (0. Xmg). |
“Trailing zero” is acceptable for reporting laboratory values and in certain other numeric notations; the digits indicate the precision of the numeric value after the decimal point, even when that trialing digit is a zero.
| 5. |
| MS |
MSO4
MgSO4 Confused for one another.
Can mean morphine sulfate or magnesium sulfate Write “morphine sulfate,” “magnesium sulfate”, “mitral stenosis” or “multiple sclerosis”
f. Pharmacy Service will report all infractions on the use of unacceptable abbreviations to the Chief of Staff (11) and Chief, HIMS (136D) for noncompliance patterns and opportunities for improvement.
g. Pharmacy Service will verify any medication order that contains questionable abbreviations with the prescriber before it is filled.
h. Proposed additions to, or deletions from, the list will be submitted through the Chief of the respective service through the Medical Records Committee to the Medical Executive Council (MEC).
i. The Medical Records Committee is responsible for periodic review and update of abbreviations used in health records.
6. DEFINITIONS
None
7. REFERENCES
a. VHA Directive 1907.01, current edition.
b. Joint Commission Comprehensive Accreditation Manual for Hospitals, current edition.
8. REVIEW
MCPs are reviewed annually, recertified five (5) years form the date of issue or previous recertification, and updated as needed when new guidelines (VHA handbooks, directives, accreditation standards, regulatory agency standards, etc.) are received.
9. RECERTIFICATION
This MCP is scheduled for recertification on or before the last working day of November 2027. This MCP will continue to serve as local policy until it is recertified or rescinded. In the event of contradiction with national policy, the national policy supersedes and controls.
10. SIGNATORY AUTHORITY
_________/s/__________________________________
STEPHANIE YOUNG
Executive Director Date Approved: November 28, 2022_______________ NOTE: The signature remains valid until rescinded by an appropriate administrative action.
DISTRIBUTION: MCPs are available at:
Asheville Medical Center Policies - All Documents (sharepoint.com) This is an internal VA Web site that is not available to the public.
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