Health Information Management

Ask the expert: The use prohibited abbreviations in non-order medication-related documentation

HIM-HIPAA Insider, August 7, 2007

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Q: Why can't we use prohibited abbreviations in non-order medication-related documentation, such as progress notes?

A: The simple explanation is that it makes it too complicated if you can use these abbreviations in some places but not others. The Joint Commission (formerly JCAHO) says it's because progress notes are important forms of communication between providers. However, having an approved list of abbreviations is too much to ask of your providers, says John Rosing, MHA, FACHE, practice director of accreditation and regulatory compliance at The Greeley Company in Marblehead, MA. "I think it is wise to focus on the handful of abbreviations to not use as opposed to expecting practitioners to focus on the thousands of abbreviations that can be used," he adds.

Editor's note: This question and answer appeared in the August 2007 issue of Briefings on The Joint Commission. For more information, click here.



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