JCAHO Do Not Use Abbreviations List
Posted By: MQQA on 2009-02-03
In Reply to: med help - CathyC
This link will take you to the JCAHO site with the "Do Not Use" abbreviations list. Most of the questions you are asking here (i.e. q.d. now being "daily") will be answered on this site.
BOS just came out with a 3rd edition, but not many are using that yet. Try to get a copy of the 2nd edition - it will answer a LOT of questions that will come up for you.
Good luck and welcome back! :-)
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- med help - CathyC
- JCAHO Do Not Use Abbreviations List - MQQA
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JCAHO dangerous abbreviations
Do physician offices/clinic notes need to comply with this list? I thought JCAHO was joint commission for hospital compliance.
FYI on the Do not use list per AAMT BOS and JCAHO
Hi everyone! I know this is not going to be easy but we all need to start abiding by the dangerous abbreviation list below and the JCAHO updated list attached. The biggest change will be the "q.d." Please start making these changes immediately. I would suggest putting some of them in your auto correct as it will probably be very helpful. You could put it in there as q.d. and change to daily so if you were to type q.d. by accident, it would change it automatically to daily.
We will give you a few months to get used to these changes and probably by February, we will take points off for QR if any of these errors are found.
Thank you and if you have any questions, please let the QA team know.
POLICY
Dangerous abbreviations listed below are NOT to be used.
Abbreviation
Potential Problem
Preferred Term
U (for unit)
Mistaken as zero, four, or cc.
Write “unit”
IU (for international unit)
Mistaken for IV (intravenous) or 10 (ten)
Write “international unit”
Q.D.
Q.O.D
Q.I.D.
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” and “four times a day.
Trailing zero (X.0 mg)
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.X mg)
MS
MSO4
MgSO4
Confused for one another. Can mean morphine sulfate or magnesium sulfate.
Write “morphine sulfate” or “magnesium sulfate”
TIW (Three times weekly)
Confused for twice weekly
Write “three times weekly”
mg
(for microgram)
Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose.
Write "mcg"
ZnSO4 Can be confused with IV electrolytes
Write “zinc sulfate”
Per os Can be mistaken for “left eye”
Use “PO”, “by mouth,” or “orally”
HERE IS WHAT I HAVE!!! ATTACHED IS FROM THE JCAHO SITE PER THEIR FAQ PAGE ALSO. MAYBE WE CAN ALL REACH A COMMON GROUND HERE AND BE ON THE EXACT PAGE WITHIN THE REGULATORY RULES TOGETHER.
A "minimum list" of dangerous abbreviations, acronyms and symbols
Beginning January 1, 2004, the following items must be included on
each accredited organization's "Do not use" list:
Set
Item
Abbreviation
Potential Problem
Preferred Term
1.
1.
U (for unit)
Mistaken as zero, four or cc.
Write "unit"
2.
2.
IU (for international unit)
Mistaken as IV (intravenous) or 10 (ten)
Write "international unit"
3.
3.
4.
Q.D.,
Q.O.D.
(Latin abbreviation for once daily and 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"
4.
5.
6.
Trailing zero
(X.0 mg),
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.X mg)
5.
7.
8.
9.
MS
MSO4
MgSO4
Confused for one another
Can mean morphine sulfate or magnesium sulfate
Write "morphine sulfate" or "magnesium sulfate"
In addition to the "minimum required list"
The following items should also be considered when expanding the "Do not use" list to include the additional three or more items referenced in the JCAHOFAQ@jcaho.org
Abbreviation
Potential Problem
Preferred Term
µg
(for microgram)
Mistaken for mg (milligrams) resulting in one thousand-fold dosing overdose
Write "mcg"
H.S.
(for half-strength or Latin abbreviation for bedtime)
Mistaken for either half-strength or hour of sleep (at bedtime) q.H.S. mistaken for every hour. All can result in a dosing error.
Write out "half-strength" or "at bedtime"
T.I.W.
(for three times a week)
Mistaken for three times a day or twice weekly resulting in an overdose
Write "3 times weekly" or "three times weekly"
S.C. or S.Q.
(for subcutaneous)
Mistaken as SL for sublingual, or "5 every"
Write "Sub-Q", "subQ", or "subcutaneously"
D/C
(for discharge)
Interpreted as discontinue whatever medications follow (typically discharge meds).
Write "discharge"
c.c.
(for cubic centimeter)
Mistaken for U (units) when poorly written.
Write "ml" for milliliters
A.S., A.D., A.U.
(Latin abbreviation for left, right, or both ears)O.S., O.D., O.U.(Latin abbreviation for left, right, or both eyes)
Mistaken for each other
(e.g., AS for OS, AD for OD, AU for OU, etc.)
Write: "left ear," "right ear" or "both ears;" "left eye," "right eye," or "both eyes
JCAHO has created a set of Frequently Asked Questions (FAQs) that explain the new requirements in greater detail.
List of abbreviations
Yes, they are quite certain how wonderful that "dangerous abbreviations" list is, but don't kid yourself. There are quite a few physicians out there/facilities who don't care for the list and want abbreviations (and dictate them too) the former way; --- q.i.d., q.o.d., t.i.w., q. week, q. Monday, Wednesday, Friday, etc. Shall I go on? I know because I've transcribed from physicians dictating just this way. The docs want it THEIR WAY. Get over yourself.
I have used a list of abbreviations for years.. sm
but just switched from ShortHand to Instant Text and there are problems with my old Shorthand import into IT that don't seem to be able to be resolved with tech support. I am faced with creating a new glossary though I may be able to pick and choose the largest blocks of text to transfer. It is the smaller phrases/words that will take the most time to redo as I have thousands of them and the thought of starting over is too painful so I was thinking of buying Jon Knowles list to give me a much needed boost. I am open to other ideas or suggestions!
Mary Morken's 2007 list of abbreviations SM
You can import Mary's list, or just copy it onto a CD or a little flash drive, I think it might be too big to print it out. Looking it over will give you a good idea of how to go about adding to your own list as well. There are 600+ dictators on the account I work on, so keeping whole reports doesn't work too well for me, and I have tried to make shortcuts for phrases instead. Also for capitalizing drug names that need it, and for correcting my most common errors. Happy New Year! Wise
I think you need to look up JCAHO SM
prohibited abbreviations and you will see why you cannot type this. We are talking about acute care here--not some family practice clinic. You must follow JCAHO's directive on abbreviations or the facility receives deficiencies if the organization happens to check that record.
JCAHO has prohibited q.d. and q.i.d. SM
so that is why these 2 are no longer used in any facility that is accredited by that organization.
It is JCAHO. The most misspelled acronym in medicine! nm
x
JCAHO and AAMT is a crock. Patient safety means not hiring DIMWITS
who can't read or retain what they have been taught. If you don't know what TYPED p.o. means or are confused, do not take care of patients. You are obviously too stupid. Go flip burgers somewhere where someone can instruct you every step of the way and you can do no harm. No brainer. Just a little wrist action and by all means DON'T TOUCH THE HOT GRILL. Think you can remember what that means. HEAT BAD!
abbreviations
On anything that I want expanded and is also used as an abbreviation, I put an x at the end. Such as CHF, I have it as chf and will capitalize and then chfx will spell out congestive heart failure without a problem. I do this for all my abbreviations. Hope this helps.
Abbreviations
I was thinking you could benefit from using a popular website for medical abbreviations. The sites are:
1) www.medilexicon.com
2) www.pharma-lexicon.com
You would enter the abbreviation and it will give you the definition. This is, of course, in addition, to your usual research methods using the search engine such as www.google.com
abbreviations
I do abbreviations like CHF is CHF and chff is congestive heart failure. whatever it is I just double the last letter to get spelled out version.
abbreviations
http://www.medicalabbreviations.biz
ABBREVIATIONS - nm
X
abbreviations sm
I was taught years ago never to abbreviate in a diagnosis. I also would spell it out and put the abbreviation in parentheses as this is his direct dictation and that's how I've always done it. The BOS may disagree but never got called on it. I once wrote a physician a sticky note to please not dictate his diagnoses in abbreviations as they may be misinterpreted. He was nasty about it, but it is a very dangerous thing to do.
Abbreviations
What is proper abbreviation for A Fib?
Abbreviations
Thanks. Thought it was a. fib. but saw it somewhere as A Fib and thought I was wrong. Looked in Stedman's Abbrev and it says AFib
I think it is best not to use abbreviations as much as possible.
In my opinion, I would prefer it typed "okay", but every company has their own opinion. If she is the boss, do it her way.
MM's abbreviations
You would have to add MM's expansions to Smartype yourself, one at a time. Here is a link for her abbreviations:
http://www.mtdaily.com/abbvs.txt
I use Barb Grow's vocabulary that I bought from her about 7 years ago. I don't have contact info for her now though, and I don't know if she still offers her vocabulary. I'd be lost without it. It makes much more sense than what the original Smartype or Stedmans came up with in their vocabularies. Her vocabulary is in the vcb format that goes into Smartype, ready to use.
abbreviations help
try this website:
http://www.medilexicon.com
medical abbreviation list and medical drug list
Hi,
Anyone there who could help me out finding the latest abbreviations list.
I even want the latest drug list because my current program does not have many drugs.
So if anyone could suggest anything which is available online for informationd quick look purposes.
any help for medical abbreviation list and medical drug list would be very helpful.
backing up abbreviations
I'd like to make a backup copy of all my abbreviations on Word Expander. I use Bayscribe for my work. Does anybody know how I can go about backing these up? I'm concerned that all it would take would be a virus or something funky to happen to my PC, and I'd lose all those abbreviations. I have stored over 2,000 my own abbreviations for a total of over 60,000 characters and would really regret all that work if something happened. Thanks. 
backing up abbreviations
Thank you VERY much for the info! Makes sense to me. I'll give it a try. 
dangerous abbreviations
It really depends on the account. Some facilities/doctors really don't care for the new set of guidelines and want their work verbatim precisely. But employers want it practiced just in case for some of the more confusing abbreviations.
need help on abbreviations board please...thanks
message abbreviations
What do sm and NM stand for? Is there a place to look up abbreviations used on this site?
I use the 1 after a lot of my abbreviations. How about cyto1? nm
nm
Invalid abbreviations
Sorry, was reading quickly and missed where it was saying invalid abbreviations AND mixed Latin/English abbreviations. The actual paragraph reads:
Invalid Latin abbreviations such as q.a.m. (every morning) and mixed Latin and English abbreviations such as q.4 hours (every 4 hours) have become commonplace. However, as with all abbreviations, avoid those that are obscure (like a.c.b. for before breakfast) or dangerous. For example, b.i.w. is both obscure and dangerous. It is intended to mean twice weekly but it could be mistaken for twice daily, resulting in a dosage frequency seven times that intended. Copyright (c) 2002 American Association for Medical Transcription
Sorry for any confusion.
I think with the prohibited abbreviations
to spell them out is essentially typing vertabim- it is what the doctor said, you are not changing it. If a doctor is foolish enough to complain about that knowing the penalty for each incidence of a prohibited abbreviation then he needs to get his head out of his hind end.
I would check with your supervisor but surely when they say verbatim they mean not changing the sentence structure around or what have you. I can't imagine they would want you to type these abbreviations just because the doctor says it.
Medical Abbreviations
A really cool site for searching medical abbrevitions
Yes - it helped w/abbreviations, etc.
I think it helps to broaden your knowledge of certain standards if you're job hunting, even if you've never used them. For example, you won't be surprised when you get a different job or client and someone chews you out about starting a sentence as "27-year-old patient comes in today" (versus "This 27-year-old..." or "Twenty-seven-year-old..."). JMHO and IME
Suggestion/Abbreviations
I'd like to make a suggestion to MTStars. There are so many abbreviations used on this web site and I often am unsure what they refer to. I'd like to suggest that you create a board with the definitions of these abbreviations that we can refer to as we are reading. I've been in this business for 18+ years and still many of the abbreviations are unfamiliar to me. I am sometimes able to figure them out, but sometimes I'm just not sure. I find your newsletter very interesting and helpful and a help tool like this would only add to it. Thanks for taking the time to consider this.
Dangerous Abbreviations
Q.D., QD, q.d., qd (daily) = Mistaken for each other = Write "daily".
I woud say this should over ride anything BOS has to say, but we aim to please the client. As transcriptionists though we should be aware of these dangerous abbreviations since it can affect a patient's medical record and how it is interpreted.
Abbreviations Book
Can someone recommend a good abbreviations book or a good website to use as a resource? I have Stedman's Abbreviations and I am not that happy with it. Thanks in advance!
Dangerous Abbreviations
"IV" isn't on the Joint Commission list of dangerous abbreviations. Don't take this as an indication that you're getting old--the confusion surrounding those darned abbreviations can be aggravating.
Here are some reasons for the aggravation. You might have seen it on a facility's list in the past or you might have encountered it as a recommendation from a consultant or in a journal article. Before The Joint Commission solidified its list of dangerous abbreviations, there was a lot of confusion about this--some groups banned any and all abbreviations.
There is an abbreviation that is banned because it can be CONFUSED WITH "IV." It's "IU," the abbreviation for "international unit." While it's OK to use IV, some facilities do not want you to use it, reasoning that if IU can be confused with IV, then IV can be confused with IU. And then some would want you to avoid using IV, until they discover that they have to pay extra for you to transcribe "intravenously."
Here is a link to the whole list. The document on The Joint Commission website was broken, so this link is to another website, but it is the same thing. http://www.aapmr.org/hpl/pracguide/jcahosymbols.htm
How would they know what abbreviations you used. (No message)
x
She does mention the abbreviations in
x
Thoughts on dangerous abbreviations
You're partly right. Joint Commission has no jurisdiction over a private office setting; however, this was adopted by Joint after it was first given to the national pharmacy assocition. When a doctor has his/her nurse phone in a prescription or writes one himself regardless of private office or inpatient setting, s/he better follow these guidelines.
Having worked in a pharmacy, I understand how critical it is to be able to know EXACTLY what the doctor wants the patient to have presribed. Pharmacy is going down the same path as MT work. Notice how many insurers allow for your prescriptions to go to a mail order company who will fill up to three months of your prescriptions at a time. The first line of defense these companies have (well, really just one anymore as they are becoming the MQ of pharmacies), is to scan the prescription. If it is not written clearly, a body must contact that physician. Addtionally these mail order companies allow MDs to relay prescriptions online. These guidelines better be followed or they will be contacted.
Depending on which division within the mail order pharmacy you work, a tech may fill more than 100 prescriptions an hour. If ONE of those prescriptions is filled incorrectly, it is reported to the State Board of Pharmacy who requires a monetary penalty be forwarded by the company depending on the error classification. If there are too many errors in a given month, the pharmacy is shut down, the supervising PHARMACIST receives (typically) a $5000 fine and a one month to five year suspension of practice, all actions of which are published and distributed to all 50 states in a monthly newsletter.
To say this is all AAMT's fault is ludicrous. To say the doctors are not going to change their ways because they have god complexes is ludicrous. This happened because too many mistakes were being made through haste, bad handwriting, lack of time to thoughtfully write prescriptions, etc. This is today's reality. If you do not adapt, you do not survive. Just ask a Cro-Magnon.
d~
Grrr! I just had a doc who spelled the abbreviations!
COPD, that's captial C, capital O, capital P, captial D. LAD, capital L, capital A, capital D.
Plus...
Patient has been in drug recovery - that's R-E-C-O-V-E-R-Y
Really? I did not know that. Thanks so much.
I use Stedman's Abbreviations, Acronyms, and
Symbols. Works nicely. I also go to www.medilexicon.com quite often. Using that website prevents me from having to stop and look it up in the book.
Are these abbreviations taken? I'm seriously considering starting my OWN association sm
and calling it AMTS: AMERICAN Medical Transcription Society and leave the AAMT or whatever their new name is, to the transcription WORLD.
My "society" would be kind of like them but the only difference is that absolutely NO oversea members would be allowed; only those American MTs working in other countries who could prove to the society or association that they are, in fact, American Born and Bred.
What do you say? I would charge a minimal amount per year and begin local chapters.....by contacting local colleges and tech schools and employers telling them about our local networking, American, society or association.
I would periodically work with large MT companies and large hospitals telling them of our highly skilled MTs and DEMANDING that pay be increased and showing them why American MTs are the way to go......Doesn't that sound like fun? It wouldn't be anything like a union, as I don't believe in unions, but a UNION of MTs around this great country I call MY AMERICA!
GOD BLESS AMERICA AND GOD BLESS YOU!!!!! Allah and Buddha could bless the AAMT all they want, but I just don't think they will do that.
Someone posted abbreviations before this board went
bonkers and I had copied it down. When site went down, so did my copy. Does anyone have a good site for abbreviations? Thanks.
Spelling out abbreviations in the diagnosis
when told specifically not to is not following instructions.
yes. In a document, hit CTL CTL to open your abbreviations sm
then hit File and Save As. Then save them in My Documents as your name.esp e.g. Jane.esp. You should then be able to transfer them to a jump drive. Best of luck!
Make sure you expand any abbreviations that are allowable. (sm)
I'm sure you have compared being paid on characters now vs. gross lines.
Line padding is not using standard abbreviations and
11
I use Instant Text. It imported my PRD abbreviations and
it has functions to scan reports and pull out frequent phrases or words to add to the glossary. IT really makes my job a whole lot easier.
Amen! I do over 300 lph too. Have about 5000 abbreviations, been doing this for over 7 years,
and just because I do about 300 lph, give or take, doesn't my work is sloppy!! And to prove it, I just got a raise, which I take to mean I am doing a GOOD job! As you, I proof as I go.
State abbreviations. Is there some style guide in LT or MT
where they don't use the postal code standard of two caps; i.e. CA instead of CA for California?
I immediately delete any application that comes to me if it contains gross error. I'm just blown away when I see MTs and LTs with 5+ years of experience who use the "Ca" formatting. Before I blast away this latest applicant, I thought I'd stop to check if there's something out there that I'm unaware of. Out of the 12+ resumes I'm getting a day lately, at least two will contain this error so now I'm questioning myself.
Stedman's abbreviations; aconyms; and symbols--sm
and just plain Google. works for me!
Stedman's abbreviations, equipment book, a
drug book like Quick Look or Drake. I have almost all the Stedman's books. If you are doing multiple specialities I'd get as many references as you can afford. Stedman's frequently has discounts and/or free shipping and that is when I add to my library. I don't always get the newest versions, particularly if I don't use the original reference that much. I don't get a drug book every year, but about every other year.
There are lots of on-line sources, but not all are reliable and if you are like me sometimes you get on-line to look up a word and 30 minutes later you're still on-line.
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