Risks of Abbreviations in Nurse Charting Blog | Risks of Abbreviations in Nurse Charting
Healthcare 01/13/21

Risks of Abbreviations in Nurse Charting

Using abbreviations may seem like a real time-saver during documentation, especially for nurses trying to put down patient information quickly. However, using abbreviations may put you and your patient at risk if it’s not done correctly. In fact, abbreviations are more often than not likely to cause collateral damages both professionally and legally than actually make the process easier.

The reason for this is because communication is key in the nursing profession, and one of the significant ways of doing this is through documentation and charting. And if this isn’t correctly done, you not only put your patient at risk, your employer and practice are also at risk. The arbitrary use of abbreviations can be high-risk and may end up being a waste of more time.

It’s important to understand that there are risks that you’re exposed to when you misuse abbreviations. In this post, we’ll be discussing those risks and how you can appropriately navigate abbreviations.

What are the risks?

Abbreviations may confuse the reader and be misinterpreted

Sometimes, only the writer may understand what an abbreviation stands for. Sometimes, physicians may send notes to patients that don’t communicate appropriately because such messages are filled with acronyms that even nurses can’t comprehend. There are two possibilities in situations like this: either they revert to the physician to get the correct answer (which will eventually waste more time) or guess what the note meant. There’s a chance that the latter gets a misinterpretation that can have implications.

A nurse can interpret “mg” to mean “milligram” when in fact, it means “microgram”. A patient who ends up getting an overdose of medicine can have serious medical problems that may be detrimental to his life and leave its mark on the medical practitioner’s efficiency.

Abbreviations can end up being time wasters

You’ll imagine that abbreviations should make the documentation process faster, but it can end up being a timewaster for everyone involved if not correctly done. Most times, the reader of the document or message may not get the intended messages. And if the appropriate message isn’t passed across, more time will be spent trying to figure out what the correct interpretation is. It may cause a debate among the readers as different nurses may be trying to guess what the message is.

If they get it eventually, it’d have wasted much more time than was saved, and if they don’t, it may lead to grave consequences. One main reason people are more inclined to abbreviate is because of the space for documentation. Lesser space can push for more abbreviations of information, which can end up being uncommunicative and confusing.

Abbreviations can cause legal troubles

Even beyond causing medical responsibilities is the legal issue that abbreviations can bring upon you. Most times, incorrectly using abbreviations can cause so much trouble that the writer can get caught up in a legal situation. Medical practitioners have to protect patients, but if miscommunication caused by an abbreviation endangers such patients, it can cause legal complications for such practitioners. It’s possible that nurses or other practitioners are called upon to interpret specific documentation, especially when it’s seemingly deviated from the approved abbreviation list.

Concerning approved abbreviations, a list containing the kinds of interpretation permitted and those that are prohibited is available. In 2005, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) compiled a list of abbreviations that shouldn’t be used and referred to it as the Do Not Use list.

The Prohibited Abbreviations

Fundamentally, five prohibited abbreviations apply to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or pre-printed forms.

    • U (unit) isn’t permitted because it can be mistaken for a lot of things like “0”, “4”, or “cc” at the same time.
    • IU (International Unit) is prohibited because it’s easily mistaken for the “IV” “10” (ten).
    • D., QD, q.d., qd (daily) and Q.O.D., QOD, q.o.d., qod (every other day) have been prohibited because they’re easily mistaken for each other.
    • A “trailing zero” (X.0 mg) or lack of a “leading zero” (.X mg) as the decimal point is often missed by the writer or reader.
    • “MS,” “MSO4,” and “MgSO4” have been restricted because the chances of them being mistaken for each other is high. Full words instead of abbreviations are used.

Aside from these prohibitions, the essential rule with abbreviations is that you’re required to be careful when using them. As a nurse, you can follow the following exercise of care:

    • Use the least number of abbreviations in your documentations. Also, be consistent with those you use.
    • Always clarify misconceptions before assuming what they mean.
    • Use your facility prescribed abbreviation list and keep track of them from time to time.
    • Keep track of the abbreviation trends, read the lists published in major textbooks.

Conclusion

Many charting and documentation problems are attributed to abbreviation and miscommunication on the writers’ part. It’s going to take a much longer period before electronic medical records become the norm in the medical field, so it’s more advisable to tackle the abbreviation and human error problems that we have, as much as we can.

Avoid unnecessary abbreviations, but if you must, think it through properly before using them. Stay clear of medical and professional jeopardy by avoiding abbreviations that you don’t know.

Get Insured

All nurses should have professional liability insurance (also known as errors and omissions coverage), independent of their employer. If your charts are misinterpreted and lead to improper care of a patient, you could be named in a lawsuit along with your employer. Having insurance safeguards the nurse from financial impact and provides assistance in handling the fallout from mistakes and oversights that result from simply being human.

NOW Insurance can help protect your career with a Professional Liability policy for nurses. For a quick quote fill out our application.

Blog

Tips for protecting yourself and your business.

Healthcare

Malpractice Insurance FAQs: What Is a “Retro Date”?

Pharmacy

Why You Should #ThankAPharmacist This Month

Mental Health

Why School Counselors Should Consider Malpractice Insurance

Insurance Basics

Am I Legally Required to Get Small Business Insurance?

Occupational Therapy

Liability Risks for Occupational Therapists

Insurance Basics

What Are the Exclusions on a General Liability Insurance Policy?

Nurses

Nurse Liability Insurance: 7 Reasons to Get a Policy Even If Your Workplace Is Covered

Lab Technician

Four Common Mistakes Lab Techs Make

Pharmacy

Upskilling and Reskilling in Pharmacy

Insurance Basics

How Can I Reduce My Professional Liability Insurance Cost?

Healthcare

Is Administrative Staff Covered by Medical Malpractice Insurance?

Mental Health

What Can Happen if a Clinical Counselor Doesn’t Carry Malpractice Insurance?

Mental Health

Mental Health Technicians Are More Important Than Ever in 2021

Mental Health

Why Every Counselor Should Have Malpractice Insurance (Even If You’re Just Starting Out)

Consultants

Five Reasons Why Marketing Consultants Need Insurance

Speech Therapist

Speech Therapist Insurance: What Do You Need to Cover?

Insurance Basics

General Liability and Workers’ Comp: What’s the difference?

Event Planning

What You Need to Know About Planning Your Comeback Event

Event Planning

Top Tech Tools for Hosting a Hybrid Event

Mental Health

Are You at Risk? Four Potential Liabilities When You’re an Uninsured Drug Counselor

Consultants

Consulting in the Tech Field? This is the Insurance Coverage You Need

Event Planning

How to Use Virtual Reality for Your Hybrid Event

News

Bold Penguin and NOW Insurance Partner to Make Professional Liability Insurance Easier to Quote and Bind

News

Matt Higgins Joins NOW Insurance as Executive VP of Engineering

Event Planning

Planning a Conference? You Need Event Insurance

Consultants

Five Steps to Buying Consultant Business Insurance

Nurses

Nursing Board Discipline: Know the Process

Event Planning

Eight Things Commonly Forgotten by Event Planners

Event Planning

Hybrid Events Are the New Norm – What Should Event Planners Know?

General

How Much Is Professional Liability Insurance? 6 Factors That Affect Price

Mental Health

Providing Peace of Mind: Insurance for Mental Health Workers

Mental Health

7 Reasons Rehabilitation Counselors Should Get Malpractice Insurance

Pharmacy

Pharmacy Technician: What’s Next?

Consultants

Common Mistakes When Starting a Consulting Business

Mental Health

8 Reasons a Family Counselor Should Be Insured

Mental Health

Professional Liability Insurance for Mental Health Technicians: What Does It Cover?

News

NOW Insurance Partners with Hiscox on Medical Malpractice Insurance

Healthcare

What to Know About Multi-State Healthcare Licensure

Healthcare

6 Risks of Being a Substance Abuse Counselor Without Malpractice Insurance

Healthcare

What Are the Best Upskilling Opportunities in Healthcare?

Healthcare

How Virtual Care Expands Access to Specialists

General

Thinking of Becoming a Therapist? 5 Things to Know

Healthcare

Do School Counselors Need Their Own Insurance Policy?

Healthcare

5 Rewards of Being a Mental Health Technician

Home Health

What are Key Compliance Issues in Home Healthcare?

Home Health

The Home Hospital: What Is It and How Will It Affect Future Care?

Healthcare

What Challenges Should School Counselors Expect as Schools Reopen?

Pharmacy

Sharing the Workload: Questions You Can Ask Your Pharmacist Instead of Your Doctor

Healthcare

5 Situations Where Testing Labs May Be Legally at Risk

Healthcare

Do Marriage Counselors Need Professional Liability Insurance?

Healthcare

8 Malpractice Insurance Terms Every Medical Professional Should Know

Healthcare

Social Worker Insurance: Do I Need My Own Coverage?

Mental Health

Pandemic Pressures Drive Increased Need for Mental Health Technicians

Nurses

Celebrate National Student Nurse Day on May 8

Nurses

National Nurses Week: Celebrate May 6-12

Healthcare

Why Nursing Students Need their Own Professional Liability Policy

Home Health

How to Find Affordable Professional Liability Insurance for Home Health Providers

Healthcare

5 Benefits to a Career as a Pharmacy Technician

Healthcare

How Digital Pharmacies Will Change the Industry

Healthcare

How to Become A Pharmacy Technician

Healthcare

Supporting Providers in the Age of Telehealth

Healthcare

12 Keys to Finding the Best Physical Therapist Insurance

Healthcare

When Are Lab Technicians Liable? Five Reasons to Carry Professional Liability Insurance

Healthcare

What Is and Isn’t Covered by Malpractice Insurance?

Healthcare

Why COVID Testing Labs Should Carry General Liability Insurance

Healthcare

Do Occupational Therapists Need Malpractice Insurance?

Healthcare

Can Lab Technicians Be Sued for Malpractice?

Cyber

5 Reasons Cyber Security Insurance Is Becoming More Important Than Ever

Healthcare

What Sort of Insurance Will Cover Physical Therapists?

Cyber

Helping Hesitant Patients Embrace Telehealth

Cyber

Why COVID Testing Labs Should Have Cyber Security Insurance in Case of a Data Breach

Nurses

GI Nurses and Associates Week: Highlight A GI Nurse Hero March 21-27

Nurses

What Malpractice Risks Do GI Nurses Face?

Nurses

What Kind of Nurse Should You Be? Check Out the Growing Field of Gastroenterology

Healthcare

6 Risks Lab Technicians Face Without Professional Liability Insurance

Healthcare

Do Contact Tracers Need to Protect Themselves with Professional Liability Insurance?

Cyber

Telehealth Rules Relaxed During Pandemic

Cyber

Telehealth is More Than Just Video Appointments

Healthcare

Pharmacists: Which Specialty Is Right for You?

Healthcare

Sued for Malpractice: A Guide for Nurses and NPs

Healthcare

A Guide to Medical Director Insurance and the Costs

Healthcare

2021 Trends to Look for in Occupational Therapy

Healthcare

Become a COVID-19 Contact Tracer

Healthcare

How Much Does Physician Assistant Malpractice Insurance Cost?

Healthcare

Lab Technicians: Is a Travel Job Right for You?

Home Health

Why Your Agency Needs Home Healthcare Insurance

Lab Technician

Covering Covid-19: Is Your Medical Laboratory at Risk?

Healthcare

A Complete Guide to Insurance for Physical Therapists

Healthcare

The Costs of Medical Staffing Agency Insurance

Home Health

Why Start a Non-medical Home Care Business

Healthcare

IV Nurse Day: Celebrate Jan 25

Healthcare

How to Become an IV Nurse

Healthcare

Charting by Exception: Errors by Omission or The Efficient New Norm?

Healthcare

Are You a Culturally Competent Nurse?

Healthcare

Risks of Abbreviations in Nurse Charting

Home Health

A Guide to Starting a Home Healthcare Business

Nurses

Nurses and The Good Samaritan Law

Cyber

Cyber Liability and HIPAA Compliance

Cyber

Why Hackers Love Healthcare Data

Cyber

Ransomware Rampant in Among Small Businesses

Cyber

What is the cost of a data breach?

General

NOW Insurance closes $2.5 million seed round, enhances AI-enabled platform

Cyber

Cost of a HIPAA Violation

Cyber

How to Create a Small Business Cyber Security Plan

Cyber

Small Business and Cloud Storage: Is Your Data Secure?

Cyber

Social Engineering: 7 Common Red Flags

Event Planning

Getting Liability Insurance for Events

Event Planning

Starting an Event Planning Business: A to Z

Event Planning

How Much Does Event Planning Insurance Cost?

Event Planning

Insurance for Event Planners: What You Need to Know

Event Planning

What’s Included in Event Planning Insurance Coverage?

Insurance Basics

What Can a Tax Preparer Be Held Liable For?

Insurance Basics

Tax Preparer Insurance 101

Medical Staffing

4 Nurse Staffing Issues to Avoid

General

What You Need to Know to Be a Tax Preparer

Insurance Basics

Insurance for Bookkeepers: A Complete Guide

Medical Staffing

How to Start a Nurse Staffing Agency

Insurance Basics

What is Liability Insurance for Bookkeepers?

General

How to Build Customer Relations in Your Business

Medical Staffing

A Guide to Medical Staffing Insurance

General

Developing an Effective Risk Management Plan

Insurance Basics

All You Need to Know About Therapist Insurance

Mental Health

What is Malpractice Insurance for Counselors?

Mental Health

Benefits of Therapist Liability Insurance

Insurance Basics

What’s the Average Counselor Malpractice Insurance Cost?

Insurance Basics

Risk and Hazards of Being a Massage Therapist

Insurance Basics

Do Nutritionists Need Insurance?

Insurance Basics

What’s Included In Massage Insurance Coverage?

Insurance Basics

Everything You Need to Know About Malpractice Insurance Coverage For Nutritionists

Insurance Basics

Do Massage Centers Need Insurance?

Insurance Basics

How Much Does Nutritionist Insurance Cost?

Insurance Basics

Insurance Plans For Nutritionists: Everything You Need to Know

Insurance Basics

Massage Therapy Insurance: A Beginner’s Guide

General

Coronavirus Outbreak: 3 Tips to Keep Your Healthcare Business Safe

General

Company Working From Home? Stay Safe of Cyber Attacks

Insurance Basics

Business Interruption Insurance and Coronavirus

General

4 Best Practices for Medical Workers During the COVID-19 Outbreak

Insurance Basics

Inside the Hacker’s Mind – Social Engineering

Insurance Basics

Do Consultants Need Insurance?

Insurance Basics

Fitness Center & Gym Insurance: A Beginner’s Guide

General

Should Your Company Work From Home During the Coronavirus Outbreak

Insurance Basics

Why Your Business Needs Wellness and Fitness Insurance: A Comprehensive Guide

Insurance Basics

What Is the Cost of Gym Insurance?

Insurance Basics

What Insurance Do Consultants Need?

Consultants

How Much Is Insurance For a Consultant?

Consultants

Benefits of Consulting Insurance Coverage

Healthcare

Pay as You Go Insurance for Healthcare Professionals

General

You Have Your Physician Assistant’s License: Now What?

Healthcare

Why Are You Still Buying Occurrence Malpractice Coverage?

Healthcare

What Does Malpractice Insurance Cost?

General

Physician Assistant Malpractice Coverage: A Practical Guide

Nurses

Do Student Nurses Need Malpractice Insurance?

Nurses

Ouch, You Hurt Me! Do Nurse Practitioners Need Their Own Malpractice Policy?

Nurses

What Type of Insurance Do Nurses Need?

Insurance Basics

Understanding Insurance Terms: Back to Basics

General

What Does Professional Liability Insurance Cover?

General

Types of Insurance Available for Small Business Owners

General

Potential Small Business Risks

General

General Liability Insurance: How to Keep your Business Protected

General

Choosing a Business Insurance Provider: Everything You Need to Know

General

Business Insurance Plans – Do I Need One?

General

Benefits of Professional Liability Insurance

General

What Is the Average Cost of Errors and Omissions Insurance?

General

What Is Cyber Liability Insurance?

General

What Does Errors and Omissions Insurance Cover?

Cyber

Cyber Insurance 101: Why You Need It

Cyber

What Does a Cyber Liability Policy Cover?

General

Errors and Omissions Coverage: What Is It & How Does it Work?

Cyber

What Is the Average Cost of Cyber Liability Insurance?

General

Who Needs Errors and Omissions Coverage?