6XQFUHVW +RPH +HDOWK DQG +RVSLFH $%%5(9,$7,216 $1' …May...6xqfuhvw +rph +hdowk dqg +rvslfh ... pj plooljudp pj plooljudp shufhqw 0+ phqwdo khdowk 0 + prlvw khdw 0, p\rfdugldo lqidufwlrq

Suncrest Home Health and Hospice

CHAP Hospice Operations/Revised April 2020 ©Corridor 2003

483

ABBREVIATIONS AND SYMBOLS Policy No. 6-023

PURPOSE To define acceptable and unacceptable standard abbreviations and symbols for use in clinical/service documentation. POLICY Suncrest Home Health and Hospice personnel will use standard approved abbreviations and symbols in documenting in the clinical/service record. GUIDELINES

1. Home care personnel will use the approved home care and service abbreviations when documenting in the clinical/service record. (See “Approved Home Care/Service Abbreviations” Addendum 6-023.A.)

2. Home care personnel will NOT use unapproved home care and service abbreviations when documenting in the clinical/service record. (See “Unacceptable Home Care/Service Abbreviations” Addendum 6-023.B.)

3. Additional abbreviations and symbols may be added to the standard list if approved by the Executive Director/Administrator.



485

ADDENDUM 6-023.A APPROVED HOME CARE/SERVICE ABBREVIATIONS

(Insert agency “Approved List” if developed)

Ā before A abortus aa of each AAA abdominal aortic aneurysm abd abdomen Abd abduction ABG arterial blood gas ac before meals ACL anterior cruciate ligament AD right ear ADA American Diabetic Association Add adduction ADL activities of daily living ad lib as desired A/E above elbow AE as evidenced by AF atrial fibrillation A-F Bypass Aorta-Femoral Bypass AFB acid fast bacillus AFC adult foster care AFO ankle foot orthosis AG anti-gravity AIDS acquired immune deficiency syndrome A/K above knee AKA above knee amputation alb albumin Alk phos alkaline phosphatase ALPS aphasia languate performance scale AM morning AMA against medical advice amb ambulatory AMI acute myocardial infarction amp ampule amt amount Ant anterior A/O alert and oriented a&p anterior/posterior A&P auscultation and percussion AP apical pulse APS adult protective services approx approximate appt appointment Aq water



486

ARDS adult respiratory distress syndrome ARE active resisted exercises arom active range of motion ASA acetylsalicylic acid ASAP as soon as possible ASD atrial septal defect ASHD arteriosclerotic heart disease asst assistance AV node atrioventricular node avg average AVSS afebrile, vital signs stable ax axillary Ba barium Bl bilateral bil bilateral BDAE Boston Diagnostic Aphrasia Examination BE barium enema bid twice a day biw twice a week B/K below knee BKA below knee amputation BLE bilateral lower extremities BM bowel movement BP blood pressure BPH benign prostatic hypertrophy BR bed rest BRP bathroom privileges BS blood sugar BSC bedside commode BSO bilateral salpingo-oophorectomy BT brief therapy BUE both upper extremities BUN blood urea nitrogen bx biopsy c with C centigrade C-1, C-2 first cervical vertebra, etc. ca calcium CA carcinoma CABG coronary artery bypass graft CAD coronary artery disease cal calorie caps capsule CAT computed axial tomography cath catheterize CBC complete blood count CBI continuous bladder irrigation cc cubic centimeter



487

CC chief complaint cert certificate/certification CF cystic fibrosis CGA contact guard assist CHD coronary heart disease CHF congestive heart failure CHHA certified home health aide CHI closed head injury CHO carbohydrate Chol cholesterol Chole cholecystectomy circ circulation Circ circumcision CK creatinine kinase Cl chloride Clt client cm centimeter CNS central nervous system CO cardiac output CO2 carbon dioxide coag coagulation c/o complaint of conc concentration cont continuously COPD chronic obstructive pulmonary disease cor heart (Latin) CP chest pain cp cerebral palsy CPG creatinine phosphatase CPR cardiopulmonary resuscitation creat creatinine CRP community resources planning C&S culture and sensitivity C-section cesarean section CSF cerebrospinal fluid CTA clear to auscultation CV cardiovascular CVA cerebrovascular accident CVD cardiovascular disease CVP central venous pressure cx cervix CXR chest x-ray DC discontinue D&C dilatation and curettage DDD degenerative disc disease DIC Disseminated Intravascular Coagulopathy diff differential dist distention



488

DJD degenerative joint disease DM diabetes mellitus DNR do not resuscitate DOA dead on arrival DOB date of birth DOE dyspnea on exertion dr dram drng drainage drsg dressing DS Dorsi Flexion dschg discharge DSD dry sterile dressing DSS Department of Social Services DTR deep tendon reflexes DVT deep vein thrombosis D/W dextrose and water D5W dextrose and 5% water dx diagnosis ea each ECF extended care facility ECG electrocardiogram E. coli Escherichia coli ECT electroconvulsive therapy EEG electroencephalogram EENT eyes, ears, nose and throat e.g. for example EKG electrocardiogram elix elixir EMB electromyelography EMS electrical muscle stimulation EOM extraocular movement Eq equivalent ER Emergency Room ESR eosinophilic sedimentation rate est estimated etiol etiology ETOH ethanol ext extension ext rot external rotation exp expired F Fahrenheit f Flexion FBS fasting blood sugar Fe iron Fern/Pop femoral-popliteal FH family history fld fluid flex flexion



489

FOB foot of bed freq frequent FTT failure to thrive FU follow-up FUO fever of unknown origin FWB full weightbearing fx fracture GB gallbladder GC Gonococcus GE gravity eliminated GFPT good/fair/poor/trace GI gastrointestinal GLC glaucoma gluc glucose Gm gram gr gram gt gait gtt drops GTT glucose tolerance test GU genitourinary GYN gynecology h hour HA headache hams hamstring Hcl hydrochloric acid HCO3 bicarbonate concentrate Hct hematocrit HEP home exercise program HEENT head, eyes, ears, nose, and throat Hgb hemoglobin HG home glucose monitoring H&H hemoglobin and hematocrit HHA home health aide HHN hand held nebulizer HKAFO hip, knee, ankle, foot, orthosis HIV human immunovirus HMD hyaline membrane disease HOB head of bed H&P history and physical HR heart rate hs hours of sleep ht height HTN hypertension HV home visit hx history H2O water H2O2 hydrogen peroxide HPI history of present illness



490

I&D incision and drainage IDDM insulin dependent diabetes i.e. for example IM intramuscular inc incomplete inf inferior int intermittent Int Rot internal rotation I&O intake and output IOP intraocular pressure IPPN intermittent positive pressure breathing IR internal rotation IR inferior rectus IS incentive spirometry I/S instruct and supervise IV intravenous IVPB intravenous piggyback JP Jackson Pratt jt joint jug jugular JVD jugular venous distention k potassium KCL potassium chloride Kg kilogram KO keep open KOR keep open rate L lumbar L-1, L-2 first lumbar vertebra, etc. l liter Lab laboratory lac laceration LAD left anterior descending Lap laparotomy lat lateral lb pound LBBB left bundle branch block LD left deltoid LCL lateral collateral ligament LE lower extremity lg large LGM left gluteus maximus lig ligament liq liquid LLE left lower extremity LLL left lower lobe LLO long leg orthosis LLQ left lower quadrant LMP last menstrual period



491

LNMP last normal menstrual period Lpm liters per minute LP lumbar puncture LPRD long range planning & decision-making LS lumbosacral li light LRM long-term memory LTR lateral tongue response LOB loss of balance LOC level of consciousness loc loss of consciousness LUE left upper extremity LUQ left upper quadrant LVG left ventro gluteal LVH left ventricular hypertrophy LVL left vastus lateralis lymphs lymphocytes lyte electrolytes M male MA Medicaid max maximum MBS modified barium swallow m/care Medicare mcaid Medicaid MCL medial collateral ligament MCP metacarpophalangeal joint me mistaken entry meds medications men meniscectomy mEq milliequivalent Mg magnesium mg milligram mg% milligram percent MH mental health M/H moist heat MI myocardial infarction mim minimum min minute ml milliliter mm millimeter mod moderate MOM Milk of Magnesia MOW Meals on Wheels MP metatarsophalangeal MR mental retardation MRE manual resisted exercises m.s. morphine sulfate M.S. multiple sclerosis



492

MSS Medical Social Services MTP metatarsophalangeal joint MV minute volume MVA motor vehicle accident MVV maximum voluntary ventilation N normal Na sodium N/A not applicable NaCl sodium chloride NAS no added salt NB newborn NC nasal cannula N/C no complaint neg negative NG nasogastric NG tube nasogastric feeding tube NIDDM non-insulin dependent diabetes NKA no known allergies nsg nursing NH nursing home noc night NPC non-productive cough NPO nothing by mouth NS normal saline NSR normal sinus rhythm N&T nose and throat N&V nausea and vomiting NVD neck vein distention NWB non-weight bearing O objective O2 oxygen OA osteoarthritis OB obstetrics OB-GYN obstetrics and gynecology OBS organic brain syndrome OD right eye O/E observe and evaluate oint ointment OOB out of bed opth ophthalmology OS left eye OT occupational therapy OU both eyes oz ounce p pulse P plan P&A percussion and auscultation PA pulmonary artery



493

SYMBOLS (A) ....................................... axillary (temperature) (R) ........................................ rectal (temperature) M ............................................................. murmur R .................................................................... right L ...................................................................... left 24° .......................................................... 24 hours = ................................................................. equal ∆ .............................................................. change = ......................................................... equivalent c̄ ................................................................... with s̄ .............................................................. without ā ................................................................ before

p̄ ................................................................... after " .............................................................. minutes ↑ ........................................... increased, elevated ↓ ...................................... decreased, depressed i ................................................................ one (1) ii ................................................................ two (2) "" .............................................................. check ♂ .................................................................. male ♀ ............................................................... female ║ ....................................................... parallel bars ........................................................... therefore .........roughly equal to, about, or approximately



495

ADDENDUM 6-023.B UNACCEPTABLE HOME CARE/SERVICE ABBREVIATIONS

(insert list of agency’s official “Do Not Use” list.)

There is a website for the error prone abbreviations list. It is:

www.ismp.org/tools/errorproneabbreviations.pdf



497

UACCEPTABLE HOME CARE ABBREVIATIONS The following abbreviations have been identified as error prone abbreviations and should not be used: U, u ................................................................. unit

“x”.0 mg ................ trailing zero in medication use

IU ............................................... international unit

. “X” mg .... lack of leading zero in medication use

Q.D., QD, q.d., qd ................................once daily

MS, MSO4, MgSO4 .................... morphine sulfate

Q.O.D, QOD, qod, q.o.d. ............. every other day

MS, MSO4, MgSO4 ................ magnesium sulfate

Additional abbreviations, symbols, and acronyms identified to be considered as prohibited or unacceptable include the following: ug ...................................................... micrograms

D/C ....................................................... discharge

H.S. ............................... half strength or bed-time

c.c. ............................................. cubic centimeter

T.I.W. ..................................... three times a week

A.S., A.D., A.U.................... left, right or both ears

S.C. or S.Q. ................................... subcutaneous



499

Additional Abbreviations, Acronyms and Symbols and Dose Designations (To be considered for inclusion in the agency’s Official “Do Not Use” List): Do Not Use

Potential Problem Use Instead

> (greater than) < (less than)

Misinterpreted as the number “7” (seven) or the letter “L” confused for one another

Write “greater than” Write “less than”

Abbreviations for drug names Misinterpreted due to similar abbreviations for multiple drugs

Write drug names in full

Apothecary units Unfamiliar to many practitioners, confused with metric units

Use metric units

@ Mistaken for the number “2” (two)

Write “at”

cc Mistaken for U (units) when poorly written

Write “ml” or “milliliters”

µg Mistaken for mg (milligrams) resulting in one thousand-fold overdose

Write “mcg” or micrograms

Suncrest Home Health and Hospice should also determine whether there are additional abbreviations, acronyms, symbols and dose designations that should not be used in Suncrest Home Health and Hospice and added to this list. Additional resources for dangerous abbreviations, acronyms, symbols and dose designations can be found:

www.ismp.org/MSAarticles/specialissuetable.html

www.ismp.org/Tools/errorproneabbreviations.pdf

Documents

6XQFUHVW +RPH +HDOWK DQG +RVSLFH $%%5(9,$7,216 $1' …May...6xqfuhvw +rph +hdowk dqg +rvslfh ... pj plooljudp pj plooljudp shufhqw 0+ phqwdo khdowk 0 + prlvw khdw 0, p\rfdugldo lqidufwlrq