"In this day and age of accelerated documentation and compliance requirements and pressure to reduce risk exposure, multiple abbreviations and acronyms are used to expedite the required written processes and still provide time for patient care. Unfortunately, clear, correct, concise communication as well as patient safety suffers because of the habitual use of these shortcuts."

As the federal Department of Health and Human Services moves forward with proposed changes in coding systems using SNOMED (Systematized Nomenclature of Medicine by the College of American Pathologists) as a standard, habits of abbreviation must change to comply. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other accreditation bodies are starting to require standardization of all abbreviations, acronyms and symbols in clinical documentation. These requirements include a mandate of which terms not to use.

What do all these abbreviations mean? Obs could be an obstetrical service patient, an organic brain syndrome patient, or perhaps an observation bed patient. Pt could mean anything from Platinol AQ to patient to paroxysmal tachycardia or any of the other 16 meanings of the abbreviation. At least the /c is clear; it means with — unless, of course, it is handwritten and you don't see the /, in which case it could mean any one of 13 other things, or the / is read as a 1, which increases the potential misunderstanding by another five things. MI could mean mitral insufficiency or myocardial infarction (one chronic, one acute) and up to eight other things if the I is misread as a one. What the heck is VIH? Could it be HIV written by a French- or Spanish-trained provider? Now Lasix seems clear, but without a space the dose could be misread and in a handwritten note may be milligram or microgram. And what about IVP? Is that intravenous push or should you get an intravenous pyelogram on this patient? Which leaves us with pt again. Is that an order for physical therapy or a prothrombin time?

The advantages of abbreviations include convenience, time savings and the avoidance of misspellings. But those advantages are offset by the disadvantages, which include longer training time for health care workers, wasted time to verify meanings, delays in patient care, potential and actual patient harm, and fraudulent or abusive billing patterns but if we don't put the patient first, who will? I believe the lesson is brought home by the following interaction between Alice and the Mad Hatter in Lewis Carroll's classic book: "Then you should say what you mean." "I do," Alice hastily replied, "at least — at least I mean what I say — that's the same thing, you know."


Read the full article: Here