JCAHO has prohibited q.d. and q.i.d. SM
Posted By: another MT on 2005-12-24
In Reply to: AAMT guidelines about not using q.d., q.i.d. q.h.s. etc. - Totally confused sm
so that is why these 2 are no longer used in any facility that is accredited by that organization.
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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.
As I stated, the company has prohibited taking SM
time off now, until further notice.
My question was do they have to return to us or could they simply eliminate it completely. I suppose the answer is they can do anything they want.
Testing question (not the prohibited kind)
I am starting a job search and hope to test with a few companies. It has been a while since I have done this so I need your input.
When transcribing a file, should it just be typed verbatim or should I expand the abbreviations?
TIA :)
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.
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.
JCAHO dangerous abbreviations
Do physician offices/clinic notes need to comply with this list? I thought JCAHO was joint commission for hospital compliance.
JCAHO Do Not Use Abbreviations List
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! :-)
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!
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