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ADHI Ch9
Abbreviations
| Question | Answer |
|---|---|
| Joint Commission mandates that in order to be accredited as an acute care facility, hospital should use | uniform data whenever possible |
| synonymous w/any short expression that is perceived to represent a longer word/group of words | abbreviation |
| abbreviation formed from initial letters of each of successive words/major parts of compound term, or of selected letter of word/phrase that is pronounced as a word | acronym |
| abbreviation formed from initial letter of each of successive words/major parts of compound term or of selected letter of word/phrase that is not pronounces as a word but by each letter | initialism |
| abbreviation that results in shortened form of a single word rather than initial letter of series of words | brief form |
| abbreviations, acronyms, & brief forms should only be used for | internationally recognized & accepted units of measure & for widely recognized terms & symbols |
| unless abbreviation, acronym, or brief form is so widely used that it has become a term in its own right | use expanded form 1st, followed by its abbreviated form in parentheses |
| will require facilities to be contemplative & careful about abbreviations they deem acceptable | interoperability btwn disparate healthcare systems |
| do not use abbreviation when term is __ in full | dictated |
| units of measure can be abbreviated even if | they are dictated in full |
| ADHI does not recommend abbreviation of __ __ unless facility preference | dosage instructions |
| when universally recognized abbreviations are used within medical record | they do not require expansion, even 1st time referenced in a report |
| abbreviation must be __ __ if used in admission, discharge, preoperative, or postoperative diagnosis; consultative conclusion; or operative title | written out |
| always transcribe diagnosis __ __ & include dictated abbreviation in parentheses immediately following | in full |
| dictation of non-disease-entity abbreviations accompanies diagnostic & procedure statements | they may be used if dictated |
| if rare disease-entity abbreviations are better known by their abbreviations than by full delineation | it is best to leave it abbreviated |
| when abbreviated diagnosis, conclusion, or operative title is dictated & abbreviation used is not familiar/has multiple meanings | should be transcribed as dictated and flagged |
| metric units of measure that accompany numeric values &/or are part of virgule constructions | should be abbreviated |
| do not use __ with abbreviated unit of measure | periods |
| use the abbreviated unit of measure only when __ __ precedes unit of measure | numeric quantity |
| __ __ common nonmetric units of measure to express weight, depth, distance, height, length, & widths, except in tables | spell out |
| do not abbreviate __ __ units of measure, except in tables | most nonmetric |
| do not abbreviate nonmetric units in virgule constructions except when | expression combines metric unit with most nonmetric unit |
| some businesses are readily recognized by abbreviations/acronyms, & may be referred to by same if dictated & if there is | reasonable assurance business will be accurately identified by reader |
| most abbreviated forms for business entities use __ __ | all capitals |
| most abbreviated forms for business entities do not __ __ | use periods |
| when determining capitalization & punctuation of business entities, always be guided by | entity's designated abbreviated form |
| abbreviate state & territory names when they are | preceded by city, state, or territory name |
| do not abbreviate names of states, countries, or similar units within reports | when they stand alone |
| use abbreviations in state names in a(n) | address on letters/envelopes |
| avoid use of contractions in record, even if dictated, except in | direct quotations |
| when possible, extend abbreviations that contain __, particularly when they represent slang/coined terms | contractions |
| when using contractions in direct quote, take care to place __ correctly | apostrophe |
| sentence may begin with __ abbreviation, or such abbreviated forms may be __ | dictated; expanded |
| avoid separating a(n) __ from its associated unit of measure or accompanying abbreviations, keep them together at line breaks | numeral |
| when automatic word wrapping brings unit of measure to 2nd line | carry numeral with it |
| when expanding dictated abbreviation in diagnosis/operative title sections of report, place abbreviation __ __ following expanded expression | in parentheses |
| if a term is dictated in full there is no need to | include abbreviation reference |
| capitalize all letter of most acronyms, but when they are expanded do not | capitalize words from which they are formed unless they are proper names |
| do not capitalize abbreviations from __ terms | Latin |
| use __ within or at end of Latin abbreviations, but its also acceptable to drop them | periods |
| use lowercase abbreviations w/periods for Latin __ that are related to doses/dosages | abbreviations |
| avoid using all capitals for Latin abbreviations related to doses/dosages because | they emphasize abbreviation rather than drug name |
| avoid lowercase Latin abbreviations related to doses/dosages without periods because | some may be misread without words |
| do not capitalize brief form unless extended form is | routinely capitalized |
| __ capitalize most units of measure or their abbreviations | don't |
| always capitalize genus name abbreviations when they are | accompanied by species name |
| use of __ after genus name abbreviation is acceptable, but ADHI/AMA recommend dropping it | period |
| do not abbreviate species name even if | genus name is abbreviated |
| do not use periods within/at end of most abbreviations, including | acronyms, abbreviated units of measure, & brief forms |
| use period at end of abbreviated nonmetric units measure if | they may be misread without period (only in virgule constructions & tables) |
| do not use periods with __ academic degrees & credentials | abbreviated |
| use periods in lowercase __ abbreviations derived from Latin terms | drug-related |
| do not use periods w/abbreviated personal & courtesy titles unless | it is known that person in question prefers inclusion of period(s) |
| use lowercase s without apostrophe to form plural of | capitalized abbreviation, acronym, or brief form |
| use 's to form plural of | lowercase abbreviations |
| use 's to form plural of __ abbreviations | single-letter |
| add 's to most abbreviations/acronyms to | show possession |
| US Pharmacopoeia (USP), Institute for Safe Medication Practices (ISMP), US FDA, & National Coordinating Council for Medication Error Reporting & Prevention (NCCMERP) are | organizations involved in identifying & preventing problems/errors in medication orders from abbreviations |
| published list of dangerous abbreviations & dose designations as reported to USP-ISMP Medication Errors Reporting Program | US Pharmacopoeia (USP) |
| ADHI promotes adoption of dangerous abbreviations & dose designations listing from | USP-ISMP Medication Errors Reporting Program |
| almost 50% of __ __ standards directly related to patient safety in some way | Joint Commission |
| designed to improve safety measures in identified key areas of patient management & care; July 2002 Joint Commission approved | 6 National Patient Safety Goals (NPSGs) |
| improve effectiveness of communication among caregivers | Goal 2 of 2004 Joint Commission, program-specific NPSGs |
| standardize a list of abbreviations, acronyms, & symbols that are not to be used throughout the organization | 2nd directive of Goal 2 of 2004 Joint Commission, program-specific NPSGs |
| ADHI recommends learning & memorizing __ abbreviations considered dangerous & __ those abbreviations appropriately when encountering them in dictation | all; editing |
| rule for omitting trailing zeros only pertains to __ __, not to measurements outside of this domain | medication dosages |
| when author chooses to dictate trailing zero on any other measurement (i.e. describe mass, lesion, wound, etc.) this should be | transcribed as dictated |
| use of trailing zero after decimal can be __ __ on part of physician/dictator to ensure reflection of exact/precise measurement vs approx measurement | intentional inclusion |
| transcription should not assume a(n) __ measurement where none is indicated, but trailing zero should only be included if __ | precise; dictated |
| using U for unit is prohibited, although | acceptable to use when referring to certain types of insulin |
| rule for changing cc to mL only pertains to | liquid volume |
| cubic centimeter references to mass (i.e. measuring organs, tissues, & specimens of solid volume) should | be transcribed as cc |
| when cc is use to describe other non-liquid volumes, such as gas, this should be | retained & not changed to mL |
| in the case(s) of erroneously dictated dangerous abbreviations, Joint Commission recognizes the Author of a document as | person who dictates documentation to be transcribed |
| according to Joint Commission, if "do not use" term is used in dictation & dictation is clear, that term should | be transcribed as spoken; not translated or edited into its presumed meaning |
| ADHI asserts that despite recommendation by Joint Commission about erroneously dictated dangerous abbreviations MTs are still deployed in | risk management role to identify & correct erroneously dictated dangerous abbreviations & pointing it out to the facility; defer to facility policy on how to handle this issue |
| ADHI recommends MTs __ corrections recommended for full ISMP list of dangerous abbreviations | adopt |
| fundamentally it is __ that determined adoption & evolution of newly coined terms/abbreviations derived from those terms | usage |
| you should always consult __ __ when in doubt about up-to-date abbreviations or acronyms | appropriate references |
| abbreviation meaning also known as; use lower case letters w/periods to distinguish from other forms | a.k.a. |
| lowercase forms, with periods, preferred; formal publications use small capitals | a.m., AM, p.m., PM |
| abbreviations w/phrase such as in the morning, in the evening, tonight, o'clock | do not use |
| abbreviation for beats per minute | bpm/BPM |
| abbreviation for blood pressure | BP |
| write out - & + because -/+ may be easily overlooked when writing out | blood types |
| placed in patient's chart when patient/family indicates no emergency resuscitative measures are to be employed | DNR |
| courtesy title for doctors; used only for earned doctorates, not honorary doctorates; use of period acceptable, but strong trend towards omission | Dr/Dr. |
| use Dr not Doctor in __ unless it is directly to more than one doctor; do not use in plural form | salutations |
| do not use Dr/Doctor when __ are given | credentials |
| use __ abbreviations w/periods for Latin abbreviations that are related to dose/dosage | lowercase |
| avoid using all capitals, relating to dose/dosage, because they emphasize __ and not __ __ | abbreviation; drug name |
| avoid lowercase abbreviations, relating to dose/dosage, __ __ because some may be misread as words | without periods |
| when inserting a numeral (as in q.4 h.) ADHI, on the advise of ISMP, inserted a(n) __ after the numeral so that it is more easily read | space |
| correct abbreviation for: before food | a.c. |
| correct abbreviation for: twice a day | b.i.d. |
| correct abbreviation for: drops (spell out) | gtt. |
| correct abbreviation for: nothing by mouth | n.p.o. |
| correct abbreviation for: do not repeat | n.r. |
| correct abbreviation for: after food | p.c. |
| correct abbreviation for: by mouth | p.o. |
| correct abbreviation for: as needed | p.r.n. |
| correct abbreviation for: every 4 hours | q.4 h. |
| correct abbreviation for: every hour | q.h. |
| correct abbreviation for: four times a day | q.i.d. |
| correct abbreviation for: three times a day | t.i.d. |
| correct abbreviation for: as directed | u.d. |
| acceptable brief forms for examination when dictated, except as heading | exam |
| correct abbreviation for: junior/senior in names; use of periods/commas still acceptable but strong trend towards omission | Jr/Jr. & Sr/Sr. |
| correct abbreviation for: Doctor of Medicine; preferred style w/out periods; if periods used do not separate w/space w/in abbreviation | MD/M.D. |
| correct abbreviation for: milliequivalent; use with numerals; do not use periods; do not add s for plural | mEq |
| correct abbreviation for: milligrams percent; equivalent to milligrams per deciliter (mg/dL) which is preferred nomenclature, but transcribe as dictated; do not use periods; do not space btwn symbols | mg% |
| correct abbreviation for: millimeters of mercury; use w/pressure readings (BP, tourniquet pressure, etc.); need not use if not dictated | mmHg |
| correct abbreviation for: subcutaneous or subcuticular | subcu |
| when you are sure which term is intended, and subcu is dictated, spell | subcu or subcut |
| when abbreviating subcutaneous or subcuticular do not use _ _ because _ can be mistaken for medication | sub q; q |
| can serve as abbreviated forms of words/phrases in language | symbols |
| the trend is to avoid symbols in health data capture, in order to promote | interoperability & electronic exchange |
| correct symbol for: and; use w/certain single-letter abbreviations separated by the word and; so not space before/after symbol; do not use symbols in operative titles/diagnoses | ampersand (&) |
| correct symbol for expressing angles in orthopedics; write out the word or use the symbol | degrees (º) |
| correct symbol for expressing angles in imaging studies or temperature expressions | (º) |
| if (º) symbol not available you should | write out degree(s) |
| correct symbol for: expressing inches in tables, as a space-saving device | (") |
| do not use to indicate the same, instead repeat word/phrase; so not use as symbol for inches, outside of usage in tables | ditto marks (") |
| do not use these 2 symbols, except in table & mathematical expressions | (÷) & (=) |
| the word greater is over used, instead a better choice of words might be | more, longer, or over |
| many times dictating physician will read chart when dictating, and will use words that go with the __ symbol, when that may not be best translation of symbol | shorthand |
| 2 symbols often mistaken for their opposite sign in meaning, & ISMP advises against their use | (>) & (<) |
| spell out English translation when word stands alone, do not capitalize English translations; when it is part of an extended term, spell it out/use abbreviation according to preferred form | Greek letters |
| in extended terms, use of hyphen after Greek letter is __, but __ is not used after English translation | optional; hyphen |
| correct symbol for expressing minus or minus sign; write out the word if you are not certain the symbol will be noticeable or clear; also use symbol to indicate below-zero tempuratures | (-) |
| do not use except in tables or special applications, i.e. blood nomenclature; avoid because usage may cause reader to overlook it | negative sign (-) |
| use the symbol/abbreviation for number before apartment, suite, or room number only, when words apartment, suite, or room number are not used | No. or (#) |
| do not use No. or (#) before | house number in street address |
| do not use (#) to represent the words | pound(s) |
| percent is a single word; do not use abbreviation __ except in table | pct. |
| percent is a single word; use symbol after a numeral; do not space btwn numeral & symbol | (%) |
| use __ for number preceding (%); when a number is written out at beginning of sentence, __ __ percent | numerals; write out |
| do not use __ sign without a numeral | plus |
| in laboratory/technical readings, use the symbol unless it will not be noticeable/clear | plus, plus sign (+) |
| use only w/numerals; use lowercase in expression of area & volume, as multiplication symbol, & when it takes place of word times; used to express dimensions | (x) |
| use only w/numerals; use capital to express magnification | (X) |
| when word times is dictated it can be translated as for, it should be transcribed as | for rather than times or (x) |
| when words times is dictated and means number of times a thing was done, it can be transcribed | as (x) |
Created by:
lfrancois
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