Rehab

Abbreviate cautiously to alleviate documentation confusion

Rehab Regs, April 14, 2005

Abbreviations always make sense when you're the one using them, right? But sometimes shorthand can leave payers or providers without the essential information they need to make important decisions about reimbursement. Read on to learn how to abbreviate without sacrificing patient care or your facility's reimbursement.

Dodge errors with clarity

When healthcare providers think about the consequences that stem from misunderstood abbreviations, one of the most common and dangerous examples is a medication error, either in medication or dosage. For therapists, however, misunderstood abbreviations are most likely to result in reimbursement woes.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has a prohibited list of abbreviations, which is a good source to reference when you start compiling a list for your facility.

"In any rehab setting, it's important to have a 'do-not-use' list, whether you are accredited by the JCAHO or not," says Angie Phillips, PT, president and chief executive officer of Images & Associates in Amarillo, TX. "It's a safety issue."

Abbreviations are necessary because you have limited space to document the services you provide and limited time to explain them. But you must balance the need for abbreviations with readability.

Prepare your payer

Even if you can get all of your rehab staff on the same page regarding abbreviations, you still have a major problem if your payer can't understand your documentation, which must explain the patient's

  • deficit

  • interventions

  • progress

  • if and why he or she requires continued skilled services

    Because you don't want to spend all of your time writing extensively to cover these topics, the following are a few tips to mesh brevity with coherence:

  • Include a key. If you use flow sheets to document the care you provide, compile commonly used abbreviations and include them in a box on your flow sheet. Your payer will easily be able to decipher any acronyms using your key.

  • Attach an abbreviation list. Similarly, attach this list to all of the documentation you submit.

  • Call your payer(s) for guidance. Your payers may have a list of preferred abbreviations, which you may want to reference when compiling your own.

    Gather your staff

    The best way to avoid confusion is to determine which abbreviations give you problems. Phillips suggests bringing your team together to discuss abbreviations that you currently use, including those that frequently cause problems or lead to denials.

    "You want to provide a process for people to be able to understand what is written," says Phillips. "There's no regulation that says everyone has to do it the same way, but you need to be able to interpret the documentation."

    You may decide to compile a list of unacceptable abbreviations as well as an approved list-even if you aren't JCAHO-accredited. "A list of unapproved abbreviations will help you clearly get rid of the ones that are causing problems," says Irene Bartlett, rehab director at Mercy Medical Center in Des Moines, IA.

    She also suggests that facilities move away from using arrows, circles surrounding letters, and other symbols that can vary with penmanship and become difficult for others to read.

    Common abbreviation confusion

    According to staff therapists and experts alike, the following are a few abbreviations that can often be ambiguous from one provider to another:

  • Pt-patient or physical therapy

  • RTB-red Theraband or return to bed

  • tx-treatment or traction

  • TIW-twice a week or three times a week

  • hs-hamstring or heel slides

  • mod-moderate or modality

  • min-minutes or minimum

  • DC-discharge or discontinue

    Other areas of confusion

    Many abbreviations in a therapist's notes can have more than one meaning. But often there are also notations that payers may have trouble deciphering. "We try to remind staff that the purpose of documentation is to communicate," says Bartlett . "If the other person doesn't understand, you've wasted all that time you tried to save by abbreviating."

    For example, "FWW" is a common abbreviation that means "front-wheeled walker" to most therapists. But outside of rehab, you might be hard-pressed to find someone who knows that.

    Your patient's physician might not know whether "TIW" stands for "two times a week" or "three times a week," which could cause problems.

    "If the individual reading your note doesn't know what you're saying because of the abbreviations you use, then your documentation is essentially worthless," says Bartlett .

    Another example is "HEP," short for "home exercise program." Payers might not pick up the educational component of this service if they don't understand the abbreviation, says Phillips. "If they don't understand, they could disallow our services."

    Finally, abbreviations can cause confusion across healthcare disciplines. "ROM" stands for "range of motion" to the rehab industry, but for obstetrics nurses, it stands for "rupture of membrane." Anticipate who will read your notes, and abbreviate-or don't abbreviate-as appropriate.

    "Anytime we can get more clarity in what we do it's helpful," says Phillips.

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