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Alert: JCAHO surveyors are finding unapproved abbreviations in more clinical documents than just medication orders

Accreditation Connection, May 21, 2004

Check out three ways to boost compliance

Don't forget to check patient medical records for the JCAHO's unapproved abbreviations when you monitor for compliance.

Although unapproved abbreviations may appear most frequently in medication orders, the JCAHO bans nine abbreviations in all clinical documentation, including patient medical records.

In November 2003, the JCAHO issued its list of nine dangerous abbreviations, acronyms, and symbols. In April, hospitals had to add three abbreviations to the JCAHO's original list of nine.

Check out the JCAHO's National Patient Safety Goals frequently asked questions at www.jcaho.org.

Unapproved abbreviations may appear in numerous clinical documents, says Liese Harter, quality-improvement specialist at Meriter Hospital in Madison, WI. They include the following:

·  Patient profile/nursing admission assessment

·  Anesthesia history

·  Blood-glucose monitoring flowsheets

·  Medication administration record

·  Progress notes

"We're considering how to get the message out to the many practitioners involved with patient care," Harter says. "There are so many places where abbreviations are commonplace."

Click here to read more about unapproved abbreviations.

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