Abbreviations

Good morning all,
Do any of you have a sample letter that you send to the medical staff
regarding their use of dangerous abbreviations? If so, I would
appreciate receiving a copy of it.
Thank you.
«1

Comments

  • edited May 2016
    Liz: Our nursing staff flag orders that were written w/ unapproved
    abbreviations, when we receive the chart down in our dept, we copy the
    order and send the below memo to the doc



    Re: Unapproved Abbreviations


    Dear Dr: __________________

    Please find attached a copy of an order that was written using the
    unapproved abbreviation ____________________. This abbreviation has been
    identified as being dangerous because of the potential to misinterpret the
    abbreviations by those who carry out the order which could subsequently
    lead to an adverse patient safety related outcome.

    Also attached is the unapproved abbreviation listing which identifies the
    correct way to write this abbreviation. We appreciate your cooperation in
    refraining from using this abbreviation in the future to assure safe
    practices in the care we provide to our patients.


    "Liz Watson"
  • edited May 2016
    Marcia. Thank you! This is very good. Liz
  • edited May 2016
    We sent out letters to med staff and printed flash cards for all staff which did not help much. At our facility, nurses were more non-compliant than medical staff. What has helped significantly is our recent update of the multidisciplinary progress note where we have placed the do not use and the use abbreviations down the left side.
  • edited May 2016
    P. Warren, thank you very much for the information. Liz
  • edited May 2016
    When our physician's orders were reviewed, we only worked on the
    unapproved abbreviations. On the other hand, when space allows, the
    full approved abbreviation will be typed out. Our only policy relates
    to the use of unapproved abbreviations. We also have our Print Shop
    folks on alert that whenever they get a request to reprint any form,
    they are checking to see that unapproved abbreviations are not present.
    If they find them, the form is being returned to the Department for
    correction.
  • edited May 2016
    Would there be a chance that you would be willing to share your
    unapproved abbreviation policy? Thank you.

    Kris Anderson, RHIT, CCS
    415 N. Jefferson
    Wadena, MN 56482
    Phone #: 218-631-7504
    Fax #: 218-631-7587
    E mail: kris.anderson@tricountyhospital.org
  • edited May 2016
    Kris,

    Currently we only have the unapproved list of twelve. We are looking
    into have no abbreviations or limited abbreviations on the preprinted
    physician orders forms.
    Michelle
  • edited May 2016
    We actually use a committee to review every pre-printed order every
    year, and to review and approve any revisions or new ones. We do not
    allow any unapproved abbreviations, no dashes, no slashes, and any time
    there is room to write out the abbreviation, they must. Our do not use
    list is actually more extensive than JCAHO's.

    klm

    Kelley L. Meeusen
    Compliance Coordinator & Privacy Officer
    Harrison Hospital
    Bremerton WA.
    Tl: 360-792-6603
    Fx: 360-792-6607
    kelleymeeusen@hmh.westsound.net
  • edited May 2016
    Does anyone have a privacy (not security) walk-through checklist? If so,
    would you e-mail me a copy?

    Brenda W. Tuck, RHIT, CCS
    Director HIM/Privacy Officer
    Granville Medical Center
    919-690-3000 Ext 4423
    BTuck@granvillemedical.com
  • edited May 2016
    Here's what we use.
  • edited May 2016
    Here's ours . . .


    (See attached file: SELF-Assessment.doc)


    Marcia Matthias
    Director, Health Information
    Southern Illinois Healthcare
  • edited May 2016
    Here's one.
  • edited May 2016
    We are also in the process of trying to convince "the powers that be" to
    let us use a popular abbreviation publication in place of our approved
    abbreviation list. I am moving toward Stedman's but would like to know
    what others are using. Nancy



    Nancy Moran, RHIT
    Medical Records Manager
    Lodi Memorial Hospital
    Lodi, California
    (209) 339-7531 - T
    (209) 368-3745 - F

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    and delete the message. Thank you.
  • edited May 2016
    Hello All,

    The problem with using an abbreviation 'publication' is the
    abbreviations all have more than one meaning, and according to our
    policy, one abbreviation can only have one meaning. How would you work
    around this?

    Diane Dolan
  • edited May 2016
    Here is our policy. We do include reference to an abbreviation
    publication. We also realize that it would be impossible to have an
    "approved" list of abbreviations with only one meaning. Therefore our
    policy addresses that more than one meaning may exist and that
    interpretation can depend on the content of the document. Our feeling
    was that the policy is mainly an intent to address those that are
    prohibited.
  • edited May 2016
    We have a forbidden list, per TJC, a high risk list, and refer to Stedman's for the rest. We get around the issue of possible multiple meanings by saying in policy that "abbreviations must be spelled out if there is any possibility of ambiguity".

    Chris Simons, RHIA
    Director, HIMS and Privacy Officer
    Spring Harbor Hospital
    123 Andover Road
    Westbrook, Maine 04092
    simonsc@springharbor.org

    Ph 207-761-2340
    Fax 207-774-6762
  • edited May 2016
    As requested.

    Maryellen McGowan, MS, RHIA
    Director of Health Information Management
    Winthrop University Hospital
    259 First Street
    Mineola, New York 11501
    (P) 516-663-8901
    (F) 516-663-2729
  • edited May 2016
    We use Neil Davis on-line abbreviations for our Standard List. We also
    have the Hospital Unapproved List on-line as well.

    Maryellen McGowan, MS, RHIA
    Director of Health Information Management
    Winthrop University Hospital
    259 First Street
    Mineola, New York 11501
    (P) 516-663-8901
    (F) 516-663-2729
  • edited May 2016
    In our policy we address that issue by saying the approved abbreviation
    must be used in "context".

    Maryellen McGowan, MS, RHIA
    Director of Health Information Management
    Winthrop University Hospital
    259 First Street
    Mineola, New York 11501
    (P) 516-663-8901
    (F) 516-663-2729
  • edited May 2016
    We only have an unapproved and reference a book for approved.



    DeAnn Tucker, RHIT, CCS

    Owensboro Medical Health System

    Director, HIM

    Privacy Officer

    270/688-1090
  • edited May 2016
    We maintain a list of recommended abbreviations on line as an
    information tool only. OUr policy reflects "unsafe abbreviations" only.
  • edited May 2016
    DeAnn,



    Which reference book do you use? We are thinking of adopting the same
    thing here. Thanks.



    Laura J. Rizzo, MHA, RHIA

    Director, Health Information Management

    Lancaster General

    Lancaster, PA 17604-3555

    Phone: 717-544-4066

    Fax: 717-544-2709

    e-mail: ljrizzo@lancastergeneral.org
  • edited May 2016
    We do the same.



    Brenda W. Tuck, BBA, RHIT, CCS
    Director HIM/Privacy Officer
    Granville Medical Center
    919-690-3000 Ext 4423
    BTuck@granvillemedical.com
  • edited May 2016
    We have "forbidden" (May not use) and "high risk"(OK to use as long as
    not ambiguous). Other than that, Steadmans is it-- if it is in there it
    is ok to use.

    Chris Simons, RHIA
    Director, HIMS and Privacy Officer
    Spring Harbor Hospital
    123 Andover Road
    Westbrook, Maine 04092
    simonsc@springharbor.org

    Ph 207-761-2340
    Fax 207-774-6762
  • edited May 2016
    We have policy and list of "do not use" abbreviations and then have
    recently purchased Neil Davis on-line approved abbreviation list - that is
    considered are official approved abbreviation list.

    Marcia Matthias, RHIA
    Corporate Director Health Information
    Privacy Officer
    Southern Illinois Healthcare
    Carbondale, IL
  • edited May 2016
    there is a per license fee - we purchases 20 concurrent licenses for approx
    $2000. We felt it was worth it - because the edition of the books kept
    changing and we wanted everyone to have the same edition, so this seemed to
    be the simplist way to address that issue.


    Marcia Matthias, RHIA
    Corporate Director Health Information
    Privacy Officer
    Southern Illinois Healthcare
    Carbondale, IL
  • edited May 2016
    http://www.medilexicon.com/ Check this out. I believe it is free and we
    have a link to this on our intranet.

    Chris Simons, RHIA
    Director, HIMS and Privacy Officer
    Spring Harbor Hospital
    123 Andover Road
    Westbrook, Maine 04092
    simonsc@springharbor.org

    Ph 207-761-2340
    Fax 207-774-6762.
  • edited May 2016
    Joint commission only requires an unapproved. You can find an official list on their website.

    DeAnn Tucker, RHIT, CCS
    Owensboro Medical Health System
    Director, HIM
    Privacy Officer
    270/688-1090
  • We no longer have an approved list. Just a policy that states:

    tRMC will reference Stedman's Abbreviations, Acronyms and

    Symbols to standardize abbreviations, acronyms and symbols used

    in patient information documentation.

    and the "do not use" list.

    -----Original Message-----
    From: Peggy Mitchum [mailto:MitchumP@WGHS.ORG]
    Sent: Tuesday, September 02, 2008 12:04
    To: MRB Talk
    Subject: [mrb_talk] abbreviations



    Does everyone have a "approved " and "unapproved" list, and if so does Joint Commission require both approved and unapproved list.

    Thanks for your help.





    Peggy Mitchum,RHIT

    Medical Information Director

    West Georgia Health System

    1514 Vernon Road

    LaGrange, Georgia 30240

    Office Phone 706-845-3100

    Fax# 706-845-0034






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  • Thanks

    From: DeAnn Tucker [mailto:DTucker@OMHS.ORG]
    Sent: Tuesday, September 02, 2008 12:09 PM
    To: MRB Talk
    Subject: RE:[mrb_talk] abbreviations

    Joint commission only requires an unapproved. You can find an official list on their website.

    DeAnn Tucker, RHIT, CCS
    Owensboro Medical Health System
    Director, HIM
    Privacy Officer
    270/688-1090

    ________________________________
    From: Peggy Mitchum [mailto:MitchumP@WGHS.ORG]
    Sent: Tuesday, September 02, 2008 11:04 AM
    To: MRB Talk
    Subject: [mrb_talk] abbreviations

    Does everyone have a "approved " and "unapproved" list, and if so does Joint Commission require both approved and unapproved list.
    Thanks for your help.


    Peggy Mitchum,RHIT
    Medical Information Director
    West Georgia Health System
    1514 Vernon Road
    LaGrange, Georgia 30240
    Office Phone 706-845-3100
    Fax# 706-845-0034




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