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Standardize abbreviations, dose designations

Ambulatory Safety Monitor, July 21, 2005

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The topic of standardizing abbreviation and dose designation lists made its way into the 2005 revisions of the Accreditation Association for Ambulatory Health Care's (AAAHC) Accreditation Handbook for Ambulatory Health Care. A requirement that says "any abbreviations and dose designations must be standardized according to a list approved by the organization" joins the preexisting standard 6.G.

Defining the new terms

The AAAHC doesn't indicate which abbreviations and dose designations you must put on a standardized list, but it wants facilities to ensure that the list you use is approved by the organization. "We realize many organizations maintain these lists already," says Joan Riebock, the AAAHC's senior director of program operations. "We want to help these centers improve their practices and assist others in starting them." How your organization is structured will determine who approves this list. Approval may come from one of the following bodies:

• Board of directors
• Medical executive committee
• Any defined governing body

Abbreviations won't strictly apply to drugs. They could include any notation your organization uses regularly, including health practitioners' credentials and department names. Similarly, to dose designations, include those acronyms you use regularly.

Keep your lists current

Periodically review your list to keep it up to date, Riebock says. The organization should determine what periodically means for the group, however. Riebock notes that it is important to update the list when you begin to use new abbreviations or delete the ones you have discontinued.

Regardless of how you define periodically, keep your policy on the abbreviation and dose designation list current. Include the following in the policy:

• A list of abbreviations and dose designations and what each stands for
• Include language that says the clinical record is limited to the use of the following abbreviations and dose designations

Meet the whole standard

Although a new requirement has been added to standard 6.G, make sure you also continue to adhere to the original requirements. These include uniformity of content, format, and sequence of all clinical records, except when otherwise required by law.

This means you should include the same information in all clinical records, such as nursing assessments, history and physical, and any other standard content relevant to your organization. In addition, put the contents of each clinical record in the same order. For example, if the nursing assessment goes before the history and physical in patient A's record, it should be in that same order in patient B's file.

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