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.
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.
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.