Surviving Clinic in the “Real World”
Handbook for Speech-Language Pathology
SLHS 525/627
Table of Contents
1. Introduction 2. CDIS 627 Requirements 3. Off-Campus Sites 4. Reimbursement Issues 5. Documentation 6. Functional Skills 7. Communication in a Professional Setting 8. Medical Records
Appendices HIPAA Information Documentation Information Abbreviations List Abbreviations Not To Use
I. Introduction
You are about to enter “the real world” for your first experience of being a speech- language pathologist in an off-campus setting. This is your chance to explore different environments and to determine areas that you are particularly interested in (not to mention getting those all-important ASHA hours done!). The goal for your off-campus placements is to be able to “do the job” by the end of your experience. You should look on this as a job and be prepared to accept this responsibility as you would if you were being paid.
II. CDIS 627 Requirements
Clinician Requirements
A. Students placed in off-campus settings must agree to conform to the administrative policies, standards and practices of the field experience site and to the ethical and legal standards of the profession. This includes getting TB tests and Hepatitis B vaccinations and obtaining CPR certification if required by your placement.
B. You should plan on accruing a minimum of 75-100 hours in your off-campus setting. These hours may be treatment or diagnostic. You should be aware of the number and type of hours you need as you begin your off-campus experience. Your supervisor should have a method for keeping track of your hours as you accrue them in your placement; however, if s/he doesn’t, one is provided for you (forms are in the student workroom). Note your hours daily. Not only will this help you keep an accurate account of your hours but also it’s good practice for when you begin keeping billing and attendance data as a licensed and certified SLP.
C. Off-campus practicum is a job and you are expected to conform to the dress code of your placement. For hospitals and clinics, this usually means hose or socks and closed- toed shoes, covered shoulders and no midriffs showing. Hospitals may also require that your fingernails be natural, unpainted and less than ¼ inch long. Off-campus dress requirements tend to be more formal than on-campus. If you don’t know the expected dress for your placement, ask your supervisor.
D. Attendance: Most off-campus placements are open to some negotiation in terms of scheduled days off for doctor’s appointments, etc. Do not ask for time off because you have to study for a test. Also, do not wait until just before you need a day off to ask! Remember that (except for community colleges) your placements will not have things like spring break or holidays, so expect that they will want you there on those days. The placements have the right to ask you to make-up any days missed.
E. ASHA requires a minimum of 25% supervision. Your supervisor must be on-site while you are seeing clients. Your off-campus supervisors are aware of these requirements as they are reviewed at each supervisor meeting (held once a semester). However, if you feel that you are not getting adequate supervision, discuss it with your supervisor or
contact the Speech-Language Clinic Director. You must be supervised by an ASHA certified speech-language pathologist. All of the current off-campus supervisors have ASHA certification.
F. The State of California requires that only hours that are supervised by a licensed SLP may count towards the required clock hours for licensure. However, there are two exceptions to this rule: 1) public schools; and, 2) federal employees. If you are placed at Navy, the V.A. or Camp Pendleton, your supervisor may not be licensed but you may still count those hours towards licensure. The same is true for hours accrued in the public school setting for your credential.
Off-Campus Supervisor Requirements
A. Each off-campus site has entered into an affiliation agreement with SDSU. These agreements specify that the site will assign a qualified staff member to provide supervision, will provide students with “pertinent and meaningful” experiences and will complete periodic evaluations of your performance. Additionally, the agreement specifies that students will be oriented “to the field experience site administrative policies, standards and practices.” Please be sure that you receive this orientation! You need to know what is expected of you in your placement.
B. As stated previously, each off-campus placement is aware of ASHA and licensure supervision requirements and will assign supervisors appropriately. Occasionally, your regular supervisor may be absent and another staff member may supervise. If you aren’t sure of your supervisor’s ASHA or licensure status: ASK! You may not count hours that are supervised by a non-certified or non-licensed SLP. Sometimes, off-campus supervisors forget and assign students to an SLP who is in his/her Clinical Fellowship Year.
University Requirements
A. The affiliation agreements state that the University will be responsible for assuring that students are eligible for field experience, that placement will be based on an application review and personal interview process, that students will have the appropriate vaccinations, TB tests and CPR training, and that students will be provided information on Universal Precautionary Practices.
B. The Speech-Language Clinic Director will maintain communication with your off- campus supervisor. If there are any concerns regarding performance in that setting, you may be asked to schedule an appointment to discuss possible remedies.
III. Off-Campus Sites
The School of Speech, Language and Hearing Sciences maintains affiliations with every type of setting where speech-language pathology services are provided. They include:
A. Outpatient Clinics (ex. Logan Heights Family Health Center, Scottish Rite Clinic, Sharp/Rees-Stealy): These tend to be freestanding speech and language clinics and/or may be associated with health maintenance organizations (HMOs). The types of clients seen at these clinics tend to cover a broad range of ages and disorders.
B. Community Colleges (ex. Grossmont, Mesa) are supported by local, state and federal funding. Services are usually provided through Disabled Students Services and include diagnostic, educational and consultative services for students and college staff. Additionally, special programs for acquired brain injury and high tech centers service students of all ages.
C. Private Practices provide diagnostic and intervention services in a variety of settings including professional offices, skilled nursing centers and private schools. They are supported by private payments for service, payments from medical insurance and funding from state and federal programs.
D. Acute care hospitals provide speech, language, cognitive and dysphagia services to patients who have recent and/or sudden onset of illness (ex. CVA, laryngectomy) or who have recurrent disorders requiring frequent hospitalizations (complications from diabetes, respiratory or cardiac disorders). Currently, patients tend to be seen for short periods prior to their being transferred to facilities or wards requiring a lower level of care. These wards are sometimes called transitional care units, transitional living centers or step- down units. The majority of SLP services provided in acute care hospitals involve swallowing evaluation and treatment.
E. Rehabilitation centers are usually associated with a hospital (ex. Sharp Rehab, Scripps Rehab, etc.) and patients are usually followed by SLPs from the acute care portion of the hospitalization through the step-down unit and then to rehab. However, funding for “acute” rehab has been limited by many HMOs and other third-party payers (see next section on reimbursement issues). SLPs in rehabilitation settings function as part of a team with families, physicians, P.T., O.T., nursing and other allied health professionals. Patients qualifying for rehab fall under rules set by the Centers for Medicare and Medicaid (CMS), which mandates three hours of therapy per day (a.k.a. “the Three Hour Rule”). As a result, most patients receive one hour of P.T., O.T. and speech-language therapy per day.
F. Skilled nursing facilities (SNF) provide long-term care for the chronically ill and/or patients who are unable to care for themselves in more independent settings. Skilled nursing facilities also provide rehabilitation services under contract with HMOs and other third-party payers. SLPs are also part of multi-disciplinary teams in the SNF setting.
IV. Reimbursement Issues
A major part of your off-campus experience will include becoming aware of how speech- language pathologists are reimbursed for what we do. Funding for diagnostic and
intervention services is always changing due to changes in health care, the economy and laws affecting eligibility for services. In order to know how to get reimbursement (e.g., how to get your patients the services they need), clinicians should be aware of the various funding sources and generally, how each one works.
A. Health Maintenance Organizations (HMO) and Preferred Provider Organizations (PPO) are the fastest growing funding source for health care. However, services tend to be limited to a specific number of visits per year or condition, or to a specific money amount (called capitated plans). Also, some plans specifically omit speech-language and hearing services unless the disorder is acquired. For example, services for a child with a developmental language disorder would not be covered but services for a stroke would. If services are covered, the SLP usually must obtain prior authorization and provide a specified number of sessions within a limited time frame. For example, the authorization may specify 12 one-hour visits within 60 days.
B. Medicare is the national healthcare plan for persons over the age of 65 or adults who have been totally disabled for longer than two years and who were previously employed. There are two parts to Medicare. Part A covers hospitalization and Part B covers outpatient services, some medications and durable medical equipment. Medicare guidelines are set by CMS and fiscal intermediaries (Blue Cross, Aetna) process claims under contract to CMS. Claims are usually reviewed by nurses, not SLPs. As a result, it is extremely important that clinicians are aware of guidelines for Medicare documentation since your work may be reviewed by someone who is not as familiar with our work. (covered in Section V).
C. Medi-Cal is California’s version/interpretation of the national Medicaid program. This program covers persons who would not otherwise have access to medical care. This includes adults with financially and/or medically-qualifying conditions, and mothers and their children. Depending on the site, services are either pre-authorized with a treatment authorization request (TAR) or patients can use their Medi-Cal card to obtain services.
D. Regional Center for Developmental Disabilities is a California program that uses Department of Developmental Services funds and local tax dollars to fund services for children and adults with developmental disabilities. Qualifying diagnoses include mental retardation, cerebral palsy, autism, epilepsy and conditions that result in developmental delay (ex. Down Syndrome). The Regional Center is also the lead agency for California Early Start, which is California’s interpretation of P.L. 99-457. Prior to the age of 3, Regional Center may fund speech and language evaluations, individual or group therapy and/or infant programs. After the age of 3, children must have eligible diagnoses to continue to receive services. However, Regional Center does not provide speech and language therapy for children over the age of 3 since the schools should be providing those services. Regional Center does provide speech and language consultation, medical/dental care, educational and vocational planning and respite services. It is also the funding agency of last resort for augmentative communication devices.
E. California Children’s Services (CCS) is another California interpretation of a federal program to provide medical and therapeutic services to children with qualifying
diagnoses, which includes cerebral palsy, orthopedic issues and hearing loss. CCS does not cover speech therapy except for children under the age of 3 with hearing loss and children with cleft palates. There are some exceptions since CCS administers Medi-Cal funds for qualifying children. For example, CCS may pay for an augmentative communication device for children with cerebral palsy. They may also pay for rehab for a child under the age of 18 who has a traumatic brain injury.
V. Documentation
A former instructor once said, “We’re not paid for the therapy we do. We’re paid for the documentation we provide about the therapy we do.” What she meant was this: If you’re not able to document what you do in therapy, it doesn’t matter that you’re doing the best therapy ever. No one is going to know about it.” If your documentation isn’t appropriate, you will not be paid for your services. Therefore, pay attention to your off-campus supervisor when s/he orients you to the site’s paperwork and documentation procedures. Here are some principles and procedures that will be universal to the various types of sites and funding sources for services:
A. Evaluations: Evaluations off-campus are very different from on-campus. You will not have the same amount of time to review, assess and document your evaluation results. Therefore, talk to your supervisor about the format used for evaluations in your site and develop your own plan for quickly evaluating your patient. Some things to remember:
1. Evaluations results must specify type and level of functional impairment.
2. The write-up of your evaluation must be concise.
3. Your evaluation documentation should list functional goals (i.e., Patient will comprehend 2 or 3 units yes/no questions related to daily needs with 80% accuracy. NOT: Patient will demonstrate improved comprehension.).
B. Daily chart notes might be reviewed by physicians and nurses who determine if therapy is appropriate and warrants continuation. It is extremely important that the notes document and quantify progress and relate to improved functional skills. Depending on your placement, notes may be narrative or may be written in a SOAP format. They must be done daily and co-signed by your supervisor. In general, daily chart notes must be short, objective descriptions of progress.
C. Progress reports can be written every week for inpatient rehabilitation patients or once a month for patients being seen on an outpatient basis. See the appendix for examples of progress report formats. These reports summarize progress made during the treatment authorization period and, based on progress, justify continued treatment with goals to be reached during the next week or month. Since your daily chart notes will quantify your patients’ performance, using these notes to document progress will make writing your monthly progress reports easier.
VI. Emphasis on Function and Functional Skills
No matter where you are placed, your supervisor will talk to you about writing functional goals related to functional skills. This is because third-party payers will not fund services unless we are able to document that our intervention actually resulted in our patients being able to more successfully communicate in their environment. ASHA has developed the Functional Assessment of Communication Skills for Adults (ASHA FACS), which leads to measurable outcome data. See the appendix for an outline of the theoretical framework and areas assessed. Many of the field experience sites use the Functional Independence Measure (FIM), which is a national data set used in rehabilitation settings to document level of function at admission and at discharge. A copy of the speech- language items is included in the appendix.
Functional skills and goals relates to treatment of speech and language disorders in children also. Third-party payers use the same criteria for reimbursement whether you are serving children or adults. However, functional activities for children would be related to peer interactions, play-based skills and educational success.
VII. Communication in the Professional Setting
A. Team Communication: The emphasis in rehabilitation (whether in acute rehab, SNFs, or other multidisciplinary team settings) is on setting cooperative goals that incorporate a number of individual discipline’s goals. For example, the team may set a goal that the patient will be able to sequence the activities required to get from the bed to the wheelchair. The goal would mean greater independence for the patient (functional goal) and each discipline would be expected to work towards its success. From a speech perspective, this goal could mean that the SLP would work on verbal and written sequencing skills specific to wheelchair transfers and more general sequencing skills.
Most placement that use a team-based approach schedule times to meet as a team, usually called team rounds. During rounds, each discipline reports on the current level of the patient and discusses problems that may be interfering with progress. During rounds, discharge planning is also discussed.
Due to the fact that team members work so closely together, you frequently find that other disciplines comment on issues that are generally considered part of speech and language’s scope of practice. Other team members’ observations can be very helpful but it is easy at these times to become defensive or intimidated. Don’t be. You will learn a lot by listening to the other disciplines.
B. Communication with Families: Patient care conferences are scheduled while the patient is in rehab. The frequency of the conferences can vary from once a week to once a month. Usually, the team, the physician, patient and family are all in attendance. The SLP reports current level of function and goals related to the patient’s speech, language and swallowing skills. During patient care conferences, practice the following skills:
1. Do not use professional jargon. Families are under stress and may have difficulty processing the information you are providing. The use of jargon just makes it more difficult for them to understand and increases the opportunities for miscommunication.
2. Use examples to emphasize or demonstrate points.
3. Talk to the families and patients. Even if the patient doesn’t understand you, s/he deserves the respect of being talked to and not treated as if they’re not in the room.
C. Communicating with other professionals: In most settings, you will have the opportunity to communicate with a variety of professionals including physicians, nurses, other therapists, educators, etc. The one thing that everyone has in common is that they are busy! Therefore, keep communications brief and to the point. Do not be offended if people seem brusque. Please note the following during your interactions at your site:
1. If someone asks you something and you don’t know the answer, say so. It is much easier to say, “I don’t know, but I’ll find out,” than it is to give a wrong answer and have to “fix it” later.
2. Remember to stay within your scope of practice. You may not work unsupervised and you may not perform services that you were not trained to do. If you feel uncomfortable with any activities or requests for service, tell your supervisor. Some personnel at your placement may not be aware of your training status.
3. You may not take verbal or telephone orders from physicians. Only licensed SLPs can do this. If a physician or nurse wants to give you an order, tell them that you are not licensed and refer them to your supervisor.
VII. Medical Records
A. Confidentiality: See the section on HIPAA. Basically, you must maintain the same confidentiality regarding your patients in off-campus settings as you maintained on- campus. This refers to any written information as well as any verbal communications with anyone not directly involved in the patient’s care. This also means that as much as you would like to, you cannot discuss the “interesting case” you saw at the hospital with family, friends, significant others, etc.
B. You may be “sharing” medical records with other disciplines, particularly in medical settings. Everyone charts in the same chart. As a result, you should become familiar with the organization of the chart and know where to look for information. It is very helpful to read physician, nursing and other therapists’ notes to gather background information on your patient and to monitor progress. Some information that you might need from the medical chart would be:
1. Physician orders: you cannot treat the patient without the order, so check first!
2. Physician notes: usually contain something called a “History and Physical” that contains information about the patient’s history and current medical issues. Also look for daily notes, which may include information about the medical intervention plan.
3. Nurses notes: includes information about current medical status, how well and how much the patient is eating, orientation and simple communication skills.
4. Radiology reports: may tell you where the CVA or tumor is located (per CT or MRI scan) or where the aspiration is (per chest x-ray).
5. Interdisciplinary notes: contains evaluations and daily notes from therapists and allied health professionals. You may need information about participation in other treatments, progress in therapy, etc.
6. Social Work/discharge planning: contains information about where the patient may go after discharge, what level of independence they will need to achieve, who the caregivers may be and what resources are available to the patient. This information will help you plan training and discharge goals.
IX. Health Insurance Portability and Accountability Act (HIPAA)
HIPAA is a federal law, enacted in 1996 and implemented in phases beginning in October 2002. Its purpose is to protect health insurance coverage for workers and their families when they change or lose jobs. As part of this law, there were several rules that were implemented that directly affect everyone working in healthcare settings. For students, the most important is the Privacy Rule. The components of the Rule that you must know and follow are:
1. A patient’s consent must be obtained to use and disclose protected health information (PHI), including any information that identifies the patient (name, address and social security number, etc.).
2. PHI cannot be disclosed in any communication that is computer-to-computer (as in billing information), person-to-person, faxed or written, without prior consent for that specific transaction.
3. The patient has the right to inspect and correct their medical records and obtain a disclosure history (i.e., find out who the hospital has sent their information to).
You will all get an orientation to your placement’s HIPAA compliance policies and procedures. Be aware that there are huge fines and prison time associated with violating HIPAA regulations!
X. Universal Precautions and Infection Control Review the information regarding general guidelines for infection control (http://www.cdc.gov/mmwr/preview/mmwrhtml/00000039.htm). When you are off- campus, the rules are basically the same: when you may come in contact with bodily fluids, take the appropriate level of precaution to avoid catching or transmitting an infection. Generally, that means wearing gloves if you’re doing a swallowing evaluation or oral-motor exam. However, in hospitals and other healthcare settings, you are much more likely to come in contact with persons who have known infections. These patients will usually have some kind of notice posted in their medical chart or in their room saying that extra precautions are required. Ethically, you cannot refuse to treat someone based on the fact that they have an infection. If you may be pregnant or somehow at other risk, you can decline to treat a patient with a known infection as long as there is someone else available to treat.
Appendices
AFFILIATION AGREEMENT
ATTACHMENT E
EDUCATION AND DEVELOPMENT SUMMARY SHEET - #1
Title: Confidentiality of Protected Health Information (PHI)
SUMMARY This policy describes the legal and ethical responsibility for the protection of privacy and confidentially of patients protected health information (PHI). The policy establishes responsibilities and safeguards that all personnel are responsible and accountable for following. In addition, sanctions for the misuse and inappropriate access of protected health information are described in the policy. The expectation to protect health information applies to everybody that has access to the healthcare environment, whether an employee, physician, volunteer, student, intern or contractor. Your signature on the Confidentiality and Non Disclosure Agreement establishes your commitment and obligation to the protection of information.
CRITICAL EDUCATION POINTS Our Responsibilities • To protect the health information that identifies a patient, is created in the process of caring for the patient, and is kept, filed, used or shared in an oral, written or electronic format. • Determine and apply appropriate safeguards for protection of information in consideration of patient care needs and safety. • Report suspected violations of privacy and confidentiality
Minimum Necessary, Need to Know: Only access information needed to do your job. You are not allowed to view or obtain information about you, your co-workers, family, or friends.
Unauthorized Access: Accessing or communicating confidential information not associated with your job responsibility is considered a violation of this policy and will result in corrective action which may include termination of your relationship with the organization, and also have personal legal consequences.
Apply Standard Safeguards
! Know the additional privacy practices and policies specific to your department. ! Protect confidential information from unauthorized access, use or disclosure. ! Maintain physical security, access control, locked storage as appropriate, i.e., keep doors closed to secure areas, obey posted signs for restricted access to secure areas). ! Notify a clinical staff member if medical records are left unattended in public view. ! Never dispose of paper or items containing patient information in the regular trash. ! Confidential information should never be discussed in public areas, such as hallways, cafeterias, or restrooms. ! Report known or suspected violations of privacy. ! Computer passwords are unique, do not share your password or log on a computer for someone else. ! Stop and question individuals who do not belong in your work area. ! Never remove paper or items containing patient information from the facility unless authorized to do so. ! Reporting privacy concerns and suspected violations, lead to improved practices and further fosters a culture of respect for our patient's. Each of us has an obligation to report suspected violations and concerns. There will be no retaliation for reports made in good faith. Report concerns to the charge nurse or your supervisor.
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EDUCATION AND DEVELOPMENT SUMMARY SHEET - #2
Title: Provision of the Notice of Privacy Practices SUMMARY
Each hospital / facility will provide all patients accessing patient health services with a Notice of Privacy Practices. The Notice informs individuals of the permitted uses and disclosure that may be made of their health information, the individual’s rights regarding his/her information and the organizations legal responsibilities with respect to protected health information. Privacy Regulations mandate elements that must be included in a notice. All personnel should read the Notice of Privacy Practices, know their responsibility for protecting information and be able to direct individuals who have questions or complaints regarding privacy practices to the appropriate resource.
CRITICAL EDUCATION POINTS
Right to a Notice of Privacy Practices (NPP) The Notice of Privacy Practices serves to inform individuals or their legal representative of: ! Ways we may use and disclose their protected health information (PHI) ! Their rights regarding their health information ! Legal responsibilities with respect to PHI
• Required Notice elements may be found in 45 CFR 164.520
• Notice must be provided at the time of “1st” service delivery ! Patients must be provided with the NPP at least once after 4/14/03, at the first service delivery ! In emergency treatment, the notice must be provided as soon as reasonably practical ! The notice may be furnished electronically, mailed or faxed if the patient authorizes ! The Notice will be posted in service areas and on the Health care providers web site
• Acknowledgement of Receipt of the Notice ! A good faith effort must be made to obtain written acknowledgement from the patient or their legal representative that they received the notice ! If patient refuses to sign or is unavailable to sign (e.g. left before signature could be obtained), document efforts to obtain the signature ! Signed acknowledgments are retained for 6 years according to each facility’s procedures, e.g., EDI, SV3 for scanning
• Inform Patients of the “Patient / Facility Directory” ! Patient Directory includes only name, location in facility, one-word condition description and to verified members of the clergy, religious affiliation. ! Patients may restrict all or part of their information in the directory, usually at the time of inpatient admission.
• Restriction of Information If patients request restrictions on their information beyond inclusion in the Patient Directory, notify a supervisor to speak to the patient. Accommodating further restrictions to their information will be based on the scope of the request and each facility’s system capabilities to provide restrictions.
• Requests for alternate "confidential communications" Patients may request that their information be communicated in alternate manner. An example may be that a patient requests that a bill be sent to an alternate address. Access / registration staff will accommodate reasonable requests.
• Patient questions and concerns regarding our privacy practices Refer patients to your supervisor or the Privacy Officer HIPPA info.doc, Version: 3/4/2003 Page 2 of 11
EDUCATION AND DEVELOPMENT SUMMARY SHEET - #3
Title: Information, Disclosure of Patient / Facility Directory to the Public and Media SUMMARY
The privacy regulations allow the disclosure of certain information maintained in a "Patient / Facility Directory". The information contained in the directory is very limited. Patients are informed of the Patient Directory at each admission and have the opportunity to restrict entirely or limit information that may be disclosed. This policy provides guidance for the disclosure of Patient Directory information to family, friends, clergy and the media who ask for the patient by name. CRITICAL EDUCATION POINTS
Patient Directory The company will maintain a directory of individuals currently in the facility with specific information that may be released to the public, media, family, friends who inquire about the patient by name. Exception, for further protection of privacy, behavioral health and alcohol treatment patients will never be included in the Patient Directory.
At the time of admission or as soon as reasonably possible, patients will be asked if they want to be included in the Patient Directory. They may choose to include or restrict all or part of their information in the directory.
Directory Information is limited and may only be released to individuals who inquire about the patient by name, information includes: ! Patient name ! Location (e.g., Emergency Department or Inpatient) ! Condition (one word), obtain from physician or appropriate clinical staff " Undetermined: Patient is awaiting the physician and assessment " Good: Vital signs are stable and within normal limits. Patient is conscious and comfortable. Indicators are excellent " Fair: Vital signs stable, within limits. Patient is conscious but may be uncomfortable. Indicators are favorable. " Serious: Vital signs may be unstable and not within normal limits. Patient is acutely ill, indicators are questionable. " Critical: vital signs are unstable and not within normal limits. Patient may be unconscious. Indicators are unfavorable. ! Religion (available only to clergy)
Patient Restrictions: If a patient restricts their information, they are registered as "Confidential" and will not show up in the Patient Directory when an inquiry is made. Response for inquiries should be, " We do not show an individual by that name in our Patient Directory". If a caller is persistent, contact a supervisor for assistance.
Media Requests for Information:
! Media requests for information regarding a specific patient. Patient Directory information may be provided to the media if they inquire about the patient by name. If the media does not have the patient name, no information will be disclosed.
! Marketing and Communications or an Operation Supervisor should be called to respond to all media requests.
! Media should always be escorted while in the facility. Ask media members to wait in the lobby while you call your supervisor or communications representative for an escort.
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EDUCATION AND DEVELOPMENT SUMMARY SHEET - # 4
Title: Facsimile (Faxing) of Protected Health Information (PHI)
SUMMARY This policy provides staff with guidance on the appropriate use of facsimile (fax) transmission of information to ensure the confidentiality and security of information. Use of fax for communication of protected health information and the necessary safeguards to practice are addressed in this policy. CRITICAL EDUCATION POINTS Utilization of Fax transmission for communication of information will be determined using the following criteria: ! that fax transmission is the appropriate means of communication ! that sender's authority to disclose and the recipient's authority to receive information is verified ! that security status and protection requirements of information being transmitted is considered
Protected Health Information (PHI) may be transmitted by fax when: ! Original record or mail delivered copies will not meet the immediate needs of patient care ! When PHI is urgently required by a third party payor and failure to facsimile the records could result in loss of reimbursement ! Pursuant to a patient/legal representative's authorization
Authorization to Disclose PHI: Assess the need for specific patient authorization to disclose the information prior to faxing. Limit information being faxed to the minimum necessary: Faxed information should always be limited to the amount necessary to achieve the purpose of the communication. Limit information to effectively facilitate safety, treatment, essential healthcare operations and continuity of care.
Fax Safeguards: • Verify accuracy of fax numbers with intended recipient before sending a fax • Notify facilities that you commonly receive faxes from if your number changes • Recipients you commonly fax numbers to should be pre-programmed • When faxing PHI, verify fax number and availability of recipient prior to sending • Locate machines out of public view • Establish a routine for regular removing/distribution of incoming faxes Pre-programmed Fax Numbers: • Use pre-programmed numbers whenever possible • Pre-program number and send test fax-requesting verification of receipt
Fax Cover Sheet Requirements: • Completed cover sheets with standard confidentiality statement and disclaimer are required on all organizational fax transmissions. Exception: Routing faxing of information from department to department within the building, using a pre programmed fax number may not require a fax cover sheet. See policy for details of requirements. Misdirected faxes: • Obtain the fax number of the unintended receiver and immediately transmit a request that the material be destroyed immediately or retrieved by mail or delivery • If fax contained PHI, notify a supervisor
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EDUCATION AND DEVELOPMENT SUMMARY SHEET - #5
Title: Health Information: Access, Use and Disclosure of PHI SUMMARY To ensure the protection and confidentiality of protected health information in compliance with state and federal regulations, this policy describes the circumstances under which you may access, use and disclose protected health information as well as the types of authorization required. CRITICAL EDUCATION POINTS Staff authorized to disclose protected health information (PHI) should be familiar with all facility policies regarding the authorization and disclosure of information. Policy highlights include: Access to PHI: Access to PHI is limited to those individuals: ! Providing care and treatment ! Requiring information for payment/billing activities ! Participating in functions of health care operations
Use of PHI: The Privacy Regulations allow use and disclosure of a patient’s protected health information without a patient authorization in the following circumstances: • For providing Treatment, Payment and Health Care Operations (TPO): In order to carry out treatment, payment and healthcare operations, i.e. sharing information with other providers, transfer of patient to another facility, coordinating continuing care. Payment activities with third parties for the purpose of obtaining payment. Risk management and utilization review and performance improvement activities in support of hospital operations. • Mandated and required reporting: Staff will continue to disclose PHI as mandated or required under various state and federal regulations, i.e. abuse, assault, infectious disease, public health activities, organ and tissue donation. • Individuals Involved in the patients care: Clinical staff may share relevant information with individuals who have been identified by the patient as being involved in their care. HIV/AIDS test results, Psychiatric and Drug/Alcohol treatment Information always requires specific Patient Authorization for disclosure under all circumstances: These types of information are protected under additional regulations and must have patient authorization for release. The attending physician must be consulted prior to release of any mental/behavioral health information to a patient. Disclosure of PHI: Generally any disclosure made outside of the organization, not for the purpose of TPO or mandated by laws, requires patient authorization. Always consider the circumstance information is being released under. If in doubt, consult with Health Information Department or obtain the patients authorization. Use the standard "Authorization for Use and Disclosure of Health Information" form found on all units and in the Health Information Department. Responding to requests for information: Whenever possible, Health Information (HI) personnel should process requests for information. If HI is not available however, authorized personnel may disclose the information. It is critical that the policy and procedure is followed closely and the appropriate documentation form be completed and signed. Verify Authority and Identity: When disclosing information, verify the authority of the individual requesting information, check identification by asking for ID or use call back. Documentation of Disclosures: It is important that disclosures made outside of the organization for reasons other than TPO be documented. Complete the appropriate documentation form and ensure that it is included in the medical record or provided to the Health Information Department. This includes oral, written and electronic disclosures and disclosures made in error. Examples include, mandated and required reporting, verbal disclosures to law enforcement. Patient Access: Patients have a right to view or obtain copies of their health information. Refer the patient to Health Information department whenever possible. There are circumstances when access to records may be denied. Clinicians responding to patient's requests for access to their information should be familiar with the circumstances in which access should be denied. For patients requesting to view their open medical record, a physician order is required. Have an appropriate clinician available to review the information with the patient.
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EDUCATION AND DEVELOPMENT SUMMARY SHEET - #6
Title: Health Information: Disclosure of PHI to Law Enforcement SUMMARY The Privacy Regulations allow the disclosure of certain protected health information to law enforcement officials without the authorization of the patient. This policy describes the circumstances under which information may be released to law enforcement and the elements of information that may be released. CRITICAL EDUCATION POINTS Generally, the disclosure of Protected Health Information (PHI) to law enforcement or under state/federal law without a patient authorization is limited to the following: ! To comply with legal processes (e.g., subpoena, court order, warrant, mandated and required reporting) ! To help identify or locate suspects / fugitives (on or off premises) ! To provide information about victims of a crime ! To report crime on the premises ! To correctional institutions
Refer to Health Information Department: Requests from law enforcement or for legal processes should be referred to the Health Information Department whenever possible. In emergency situations, clinical staff may disclose non-medical PHI.
Request identity and validate authority prior to disclosing information: In all circumstances of disclosure, the requestor’s identity and authority must be validated and documented. • State and Federal Mandated and Required Reporting. California Law (CMIA) is not as broad as HIPAA. Disclosures of medical information to law enforcement is authorized pursuant to a court order, subpoena or search warrant, and/or if required by other laws. Examples include child abuse, domestic abuse, assault, neglect, subpoena, summons, and psychotherapy notes (with authorization from the note’s originator). Health care providers are required to report certain types of wounds and physical injuries, such as gunshots, stabbing, and burns, subject to applicable laws. Reference specific policies for mandated and required reporting;
• Disclosure of PHI to Law Enforcement for Suspected Felon. Location & Identification Information: In response to an inquiry regarding a specific patient, in the absence of a subpoena, court order or warrant, California Law (CMIA) limits the disclosure to non-medical information, e.g., suspect’s name, address, age, and sex; a general description of the patient’s condition, treatment and the nature of the injury, burn, poisoning, or other condition. Note: Do not disclose PHI related to the individual’s DNA or DNA analysis, dental records or typing, samples or analysis of body fluids or tissues.
• Disclosure of PHI to Law Enforcement for Victims of Crime. In responding to an official request concerning a person who is suspected of being a victim of a crime, PHI may be released with the individual’s authorization. Without an authorization, disclosure of PHI must be in the best interest of the individual in the professional judgment of the provider and limited to non-medical information. For decedent-victims: Report the suspicion that death involved criminal conduct.
• Reporting Crime to Law Enforcement – Crime on the Premises. PHI disclosure is limited to non-medical information, e.g., nature of crime, location of victim and/or suspected felon, identity, location and description of suspect.
• Permitted Disclosures to Correctional Institution - No authorization required. The company may disclose to a correctional institution or a law enforcement official having lawful custody of an inmate, if the correctional institution / law enforcement official represents that the PHI is necessary for: a. The provision of health care to such individuals b. The health and safety of such individual, other inmates, or others at the correctional institution (e.g., officers, employees, persons responsible for transporting / transferring inmates) c. You may reasonably rely on the representation of such public officials for the authority to release PHI
Document disclosures: These types of disclosures must be documented in order to be included in an accounting of disclosures if requested by the patient. Documentation may be made on a required reporting form if available, i.e., assault, abuse required forms or may be documented on a "Report of PHI Disclosure Form" or other disclosure accounting system. Place copies of required reporting form or the Report of PHI Disclosure form in the medical record or forward to the Health Information Department.
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EDUCATION AND DEVELOPMENT SUMMARY SHEET - #7
Title: Health Information: Request for Accounting of Disclosures of PHI
SUMMARY One of the new rights established in the Privacy Regulations is the patient's right to obtain an accounting of disclosures made of his/her health information. The accounting may include up to 6-year period, and generally includes disclosures that the patient may not be aware of that were made of their PHI, e.g., public health disclosures. This policy establishes procedures for how patients may obtain an accounting of disclosures as well as staff documentation procedures of disclosures that must be included in the accounting. CRITICAL EDUCATION POINTS
• The Notice of Privacy Practices informs patients of their right to obtain an accounting of disclosures of their health information. Patients are informed that they must submit a request in writing to the Health Information Department. • An accounting does not include all disclosures of a patient’s PHI. Disclosures that are made for treatment, payment and health care operations or authorized by the patient are not included. Generally, disclosures required by law and regulations are included in the accounting. Examples of these types of disclosures include: ! Disclosures required by law ! Abuse, assault, domestic violence reporting ! Judicial and administrative proceedings ! Public health activities ! Organ and tissue donation ! Research purposes
Staff making disclosures in this category must document such disclosures and forward the information to Health Information for accounting purposes or document the disclosure in the on-line system, if available at the facility.
• Documentation may be done in one of three ways: 1. Complete a "Report of PHI Disclosure". Include the form in the medical record or forward it to Health Information. The form may be used in circumstances such as verbal disclosures to law enforcement. Or when there is mandated reporting and standard reporting forms are unavailable.
2. Copy of a standard reporting form is included in the medical record. Examples include, assault, abuse, neglect reporting. These forms are completed by the individual making the disclosure and are copied to the medical record.
3. Maintaining a database of individuals whose information has been disclosed outside of the company. Examples include infection control reporting and lab reporting of infectious disease. Also included would be the IRB database of research protocols where patient information may have been viewed through a waived authorization.
• Elements of each disclosure required in the accounting are: ! Date of disclosure ! Name (and address if known) of the entity or person who received the PHI ! Brief description describing the PHI disclosed ! Brief statement describing the purpose of the disclosure of PHI (basis for the disclosure)
When Health Information receives a request for an accounting, they will review the entire medical record and available data base, i.e., infection control and IRB to compile a log of all disclosures required in the accounting. If you are unsure as to whether a disclosure is required to be accounted for, complete the Report of PHI Disclosure, the Health Information Department will determine on a case-by case basis whether the disclosure must be included in the accounting.
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EDUCATION AND DEVELOPMENT SUMMARY SHEET - #8
Title: Health Information: Request for an Amendment of PHI SUMMARY Under current California regulations and the new Privacy Regulations, patients have the right to request an amendment to their health information if they believe their information is inaccurate or incorrect or incomplete. This policy establishes procedures for the patient request to amend their health information. CRITICAL EDUCATION POINTS Privacy regulations provide patients the right to request amendments to their protected health information (PHI). For example, a patient may ask to change an entry of incorrect, incomplete, or outdated information about them such as name, birth date, or admission date. Or, the patient may ask to amend medical, diagnostic, or treatment information such as progress notes and test results. They also may request the addition of a written addendum to their health information. • The Notice of Privacy Practices provided during admission informs the patient of their right to submit a written request to amend their health information. • Refer patients who desire to amend their health information to the Health Information Department. Patients may make a request during hospitalization or after discharge. • Patients must submit their request to the Health Information Department, the request, must; ! Be submitted in writing, (Health Information will provide a form) ! Be limited to 250 words, or less, if it is a written addendum ! Include a reason for the request ! Identify others who need the amendment
• The Health Information (HI) Department must act on the request to amend a record within 60 days of receipt, or HI may obtain a one-time 30-day extension for responding to the patient’s request provided that they meet the requirements necessary for the extension. • Health Information, the physician, and/or Risk Management will review amendment requests as appropriate and determine: ! The impact on the patient’s care ! Identity of any other entities that may rely on this amended information, and, ! Provide a recommendation for agreement or denial of the amendment.
• If there is agreement for the amendment, Health Information will include the amendment in the patient’s health record and if necessary make corrections. ! Health Information will obtain authorization for the release of information to any other entity needing the amendment as identified by the patient or appropriate staff. ! The amendment becomes a permanent part of the medical record and is included with any future third party disclosures. All communication of corrections, denials and rebuttals should also be included in future disclosures. • If the amendment is denied, reason for denial will be documented. Examples of denials include: ! PHI was not created by the organization ! PHI is not part of the patient’s medical record ! Federal law forbids making the PHI in question available to the patient for inspection (e.g., psychotherapy notes) ! PHI is accurate and complete as stated
Health Information Department will be responsible for providing a written notice to the patient and continued communication and correspondence as necessary.
HIPPA info.doc, Version: 3/4/2003 Page 8 of 11
HEALTH TRAINEE
HIPAA EDUCATION VERIFICATION
Name:
School: Program:
I have received, read and understand HIPAA Privacy Training
______Signature Date
______School Representative Date
______Signature Title
Send completed forms to:
Sharp HealthCare Clinical Affiliation 8695 Spectrum Center Blvd San Diego, CA 92123
Fax: 858-499-5237
HIPPA info.doc, Version: 3/4/2003 Page 9 of 11 INTERMEDIATE PRIVACY MODULE POST-TEST DATE:______
NAME: TITLE:
LICENSE #:
Please circle the correct answer.
1. Staff may access and disclose only the amount of information necessary to achieve the purpose of the disclosure. TRUE FALSE
2. Patient or legal authorization is always required for the disclosure of the following types of information: a. HIV test results b. Alcohol and Drug treatment c. Psychiatric treatment d. All of the above
3. Patients may request an accounting of disclosures that have been made of their health information. Examples of disclosures required in the accounting include: a. Disclosures to law enforcement b. Mandated abuse, assault reporting c. Public health reporting d. All of the above
4. An authorization form from the patient is required to be completed when providing patients with copies of their health information. TRUE FALSE
5. A physician approval is required when patients request to view their open medical record. TRUE FALSE
6. When faxing information the following safeguards must be completed: a. Complete a fax cover sheet b. Verify recipient fax number c. Call to confirm fax receipt d. Disclose minimum amount of information needed for the request e. All of the above
Evaluation -Please circle your response. 1. Did this program provide you with a clear understanding of your role and Not Very Much Somewhat responsibilities for the protection of PHI? at all
2. Did this program adequately inform you of resources available for Not Very Much Somewhat access, use and disclosure of PHI? at all
3. Did this program increase your awareness of where safeguards may Not Very Much Somewhat be applied in your practices? at all
HIPPA info.doc, Version: 3/4/2003 Page 10 of 11
CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT Obligations Regarding Confidentiality Applies to all employees (including administration, managers, supervisors and applicable physicians); volunteers; agency, temporary and registry personnel; students, interns, and contracted personnel. Patient health and Sharp Organizational information is protected by law and by Sharp HealthCare policies. The intent of these laws and policies is to assure that confidentiality of information is maintained while used for business and clinical operations. In my job, I may see or hear confidential information in any form (oral, written, electronic) regarding: • Patients and/or their family members (such as patient records, test results, conversations, financial information) • Employees, physicians, volunteers and contractors (such as employment records, corrective action, disciplinary action) I AGREE TO AND ACKNOWLEDGE THE FOLLOWING: • I will protect the privacy of all business and medical information relating to our patients, members, employees and health care providers. • I know that confidential information I learn on my job does not belong to me and I have no right or ownership to it. Sharp HealthCare may take away my access to confidential information at any time. • I will not misuse confidential information and will only access information necessary to do my job. I will not disclose any confidential information unless required to do so in the official capacity of my relationship, employment or contract with Sharp HealthCare. • I will not share, change or destroy any confidential information unless it is part of my job to do so. If any of these tasks are part of my job, I will follow the correct department procedure or the instructions of my supervisor (such as shredding confidential paper). If a demand from an oversight agency, law enforcement or government agency is made upon me from outside Sharp HealthCare to disclose confidential information, I will document this by giving written notice to my supervisor. • I will only print information from a Sharp HealthCare information system when necessary for a legitimate work related purpose. I am accountable for this information until it is properly filed or disposed of. • If I have access to electronic equipment and/or records, I will keep my computer password secret and I will not share it with any unauthorized individual. I am responsible to protect my password or other access to confidential information. I understand that my use of an electronic system may be periodically monitored and audited to ensure compliance with this agreement. • I understand that I have an obligation to report to my supervisor and/or the Compliance Hotline if I think someone is misusing confidential information or is using my password. I further understand that Sharp HealthCare will not tolerate any retaliation against me for making a report. • On termination of my employment, I will return to Sharp HealthCare all copies of documents containing Sharp HealthCare’s confidential information or data in my possession or control.
I understand that failure to comply with this agreement may result in corrective action up to, and including, termination of employment or other relationships with Sharp HealthCare. I understand that I may also be subject to other remedies allowed by law. I understand that I must also comply with any laws, regulations, and Sharp HealthCare policies, including the Commitment to Principles, Privacy, Confidentiality and Security policies that address confidentiality. This agreement shall survive the termination of my official relationship, employment or contract with Sharp HealthCare.
I have read and understand this Confidentiality and Non-Disclosure Agreement, have had my questions fully addressed and have received a copy.
Date: ______Printed Name Signature
Date: ______Printed Name Witness
HIPPA info.doc, Version: 3/4/2003 Page 11 of 11 Overview of Documentation for Medicare Outpatient Therapy Services
Overview of Documentation for Medicare Outpatient Therapy Services
Documentation continues to play a critical role in evaluating the need for Medicare outpatient therapy services. Remember that documentation is usually reviewed by Medicare contract nurses, rather than speech-language pathologists (SLPs). In maintaining and submitting documentation, a SLP should not assume that the reviewer will understand why the service requires the skill of a SLP and should include additional information that may be needed by the reviewer. When in doubt, contact the Medicare contractor and request that they provide educational models or in-service staff training on documentation. You should consider coordinating this with your state speech-language-hearing association to make the invitation more attractive to the contractor and provide access to more of your colleagues. The Centers for Medicare and Medicaid Services (CMS) has outlined its minimal documentation requirements in the CMS Benefit Policy Manual Publication 100-02, Chapter 15, Section 220.3 (PDF format). Changes in the Benefit Policy Manual may also cause changes in the contractor’s Local Coverage Determinations, and SLPs should monitor their Medicare contractor’s web site for additional updates. All therapy notes must be signed by the qualified professional and include the profession credentials. When a student is assisting in the provision of services, the student may write the documentation, but it is the signature of the SLP that is required to ensure that a qualified professional is providing the service. Required Documentation
When submitting documentation to the contractor, CMS expects that the following information be provided, unless otherwise specified by the contractor: 1. Evaluation and Certified Plan of Care, including initial evaluation and reevaluation relevant to the episode being reviewed. An evaluation must include: ❍ a diagnosis and description of the specific problem being evaluated and or treated; ❍ objective measures, preferably a standardized patient assessment instrument or outcomes measurement tool related to current functional status; ❍ clinician's clinical judgment or subjective impressions of the patient’s condition; and ❍ determination of the need for treatment. 2. Certification. ❍ ensure that the patient is under the care of a physician 3. Progress Reports (when treatment exceeds 10 treatment days or 30 calendar treatment days/one month, whichever is less). The clinician must complete a progress report at least once during each
file:///D|/MyFiles/SLHS-SurvingClinicRealWorldManual/medicare_documentation2.htm (1 of 5) [5/5/2006 4:12:01 PM] Overview of Documentation for Medicare Outpatient Therapy Services interval of treatment. The progress note should include: ❍ date of the beginning of the treatment interval; ❍ date the report was written; ❍ signature of the qualified professional; ❍ objective reports of the patient's progress; ❍ objective measurements of changes in status relative to current goals; ❍ plans for continuing treatment; and ❍ changes to long and short term treatment goals. CMS provided the following example of a speech-language pathology progress note: Example The Plan states diagnosis is 787.2- Dysphagia secondary to other late effects of CVA. Patient is on a restricted diet and wants to drink thick liquids. Therapy is planned 3X week, 45 minute sessions for 6 weeks. Long term goal is to consume a mechanical soft diet with thin liquids without complications such as aspiration pneumonia. Short Term Goal 1: Patient will improve rate of laryngeal elevation/timing of closure by using the super-supraglottic swallow on saliva swallows without cues on 90% of trials. Goal 2: Patient will compensate for reduced laryngeal elevation by controlling bolus size to ½ teaspoon without cues 100%. The Progress Report for 1/3/06 to 1/29/06 states: Improved to 80% of trials;1. Improved to 80% of trials;1. Achieved.2. Achieved.2. Comments: Highly motivated; spouse assists with practicing, compliant with current restrictions. New Goal: "5. Patient will implement above strategies to swallow a sip of water without coughing for 5 consecutive trials. Mary Johns, CCC-SLP, 1/29/06." Note the provider is billing 92526 three times a week, consistent with the plan; progress is noted; skilled treatment is noted. 4. Treatment Encounter Notes (may also serve as progress report when required information is included in the notes). The purpose of the encounter note is not to document medical necessity, but to create a record of all encounters and skilled intervention. ● documentation is required for every treatment day, and every therapy service; ● the encounter note must record the name of the treatment, intervention or activity provided; ● total treatment time; and
file:///D|/MyFiles/SLHS-SurvingClinicRealWorldManual/medicare_documentation2.htm (2 of 5) [5/5/2006 4:12:01 PM] Overview of Documentation for Medicare Outpatient Therapy Services ● signature of the professional furnishing the services. If a treatment is added or changed between the progress note intervals, the change must be recorded and justified in the medical record. Frequent professional judgments resulting in upgrades to the patient’s activity show skilled treatment. Objective measurements showing improvement are very helpful. If there is no improvement, explain the setbacks, illness, new conditions or social circumstances that are impeding progress and why it is believed that progress is still attainable. Activities that are repetitive or routine, or easy enough to explain to an aide or caretaker could be questioned by the reviewer. 5. Exception to Therapy Caps. The records must justify services over the cap. A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for the use of the KX modifier. CMS states that objective evidence consists of standardized patient assessment instruments, outcomes measurement tools or measurable assessments of functional outcomes. The agency also states that the use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justification for continued treatment. While such tools are not required, CMS does state that they will enhance the justification for the need of therapy. ASHA’s National Outcomes Measurement System (NOMS) was used by the CMS to help determine the range of SLP diagnoses for the Medicare therapy cap exceptions process. Speech-language pathologists are encouraged to participate in outcomes reporting and benchmarking by becoming as NOMS-certified user. Visit ASHA's NOMS page for more information. ASHA also has other information that could assist in your documentation efforts. For additional information, contact ASHA’s Health Care Economic and Advocacy Team at [email protected].
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Related Resources: ● Medicare Part B Therapy Cap Exception Process
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A a before A/P auscultation and percussion A&B apnea and bradycardia AC acromioclavicular A-line arterial line A-P anterior-posterior A-R pulse apical-radial pulse A/C ratio albumin-coagulin ratio A/G albumin-globulin ratio A/P Anterior/Posterior A2 aortic second sound A.A. Alcoholics Anonymous AA amplitude of accommodation aa of each AAA Abdominal Aortic Aneurysm AAL anterior axillary line AAO awake, alert, oriented AB Abortion A.B. antibody A.B.C. alternate birth center abd abdomen ABE acute bacterial endocarditis ABG arterial blood gas ABN advance beneficiary notice abnor. Abnormal ABP arterial blood pressure Abst Abstract ABDV Doxorubicin (Adrimycin®), Bleomycin, Vinblastine and Dacarbazine ABX antibiotic ac before meals AC anterior chamber A.C.A. Adult Children of Alcoholics AC/A accommodative/convergence- accomodation (ratio) ACC accommodation ACCME American College of Continuing Medical Education ACE angiotensin-converting enzyme ACEI angiotensin-converting enzyme inhibitor ACH adrenal cortical hormone ACI adrenal cortical insufficiency acid phos acid phosphatase ACLS advanced cardiac life support ACT activated clotting time ACTH adrenocorticotropic hormone ACVD acute cardiovascular disease ad to, up to A.D. Assistive device AD right ear Ad lib as much as needed; as desired ADA American Diabetes Association ADD attention deficit disorders ADH antidiuretic hormone ADHD attention deficit hyperactivity disorder ADL activities of daily living ADLS Activities of Daily Living Summary Adm admit,admission Admin administer,administration ADP adenosine diphosphate
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
AE above elbow A.E. adaptive equipment AEB as evidenced by AFB acid fast bacilli; aortofemoral bypass AFDC Aid to Families with Dependent Children AFI Amiotic Fluid Index AFIB atrial fibrillation AFL atrial flutter AFO ankle foot orthosis AFSF anterior fontanel soft and flat AG abdominal girth AGA appropriate for gestational age AGG agammaglobulinemia AgNO silver nitrate AH auditory hallucinations AHD artherosclerotic heart disease AHF antihemophilic factor AHG antihemolytic globulin AI aortic insufficiency AICD automatic implantable cardioverter/ defibrillator AIDS Acquired Immune Deficiency Syndrome AIP acute ntermittent porphyria AK astigmatic keratotomy aka also known as Alb albumin Align. Alignment alk phos alkaline phosphatase ALL acute lymphoblastic leukemia; ALP alkaline phosphatase ALS amyotrophic lateral sclerosis Alt alternating am morning AM against motion AMA against medical advice A.M.A. advanced maternal age amb ambulate/ambulatory AMD age related macular degeneration AMI acute myocardial infraction AML acute myeloblastic leukemia amp ampule AMP amputation amt amount ANA antinuclear antibody ANC absolute neutrophil count Anes anesthesia;anesthesiology Anesth Anesthesiologist aniso anisocytosis ant anterior ante before AODM adult onset diabetes mellitus AOP apnea of prematurity A/P assessment/plan AP anteroposterior Ap apical pulse APA American Psychiatric Association APAP Acetominophen APC aspirin, phenacetin, caffeine APH anterior pituitary hormone APL anterior pituitary- like hormone APNA American Psychiatric Nurses’ Association
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
Approp appropiate Approx approximate appt appointment appy appendectomy aq water AR aortic regurgitation A.R. arteriolorsclerotic retinopathy ARC AIDS related complex ARC anomalous retinal correrspndence ARD acute respiratory distress ARDS adult respiratory distress syndrome ARM age related maculopathy ARMD age related macular degeneration AROM artificial rupture of membranes artic articulation AS arteriolorsclerosis ASC Ambulatory Surgery Center as tol as toleratd ASA aspirin ASA I — V American Society of Anesthesia (risk levels) one through five ASAP as soon as possible ASCAD arteriosclerotic coronary artery disease ASCVD arteriosclerotic cardiovascular heart disease ASD atrial septal defect ASH asymmetrical septal hypertrophy ASHD arteriosclerotic heart disease ASMI anteroseptal myocardial infraction ASMT assessment ASO antistreptolysin Asp Aspirate ASU Ambulatory Surgery Unit AT atrial tachycardia ATD Aid Totally Disabled atm atmosphere ATP ntermitt triphosphate ATP Assessment Triage Program attn attention Aud auditory AUL acute undifferentiated leukemia AUR FIB auricular fibrillation auto automatic, spontaneous AV atrioventricular ava available AVAD acute ventricular assist device AVB atrioventricular block AVR aortic valve replacement AWI anterior wall infarction AWMI anterior wall myocardial AWOL away without leave, same as elopement ax axilla AZ test Aschheim-Zondek test
B B Ax Cr bilateral axillary crutches B&C board and care facility BE barium enema BA bronchial asthma B.A.D. bipolar affective disorder BAK benzalkonium
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
BAL blood alcohol level bands(stabs) nonsegmental polymorphonuclears Barbs barbiturates Baso basophil BBB bundle branch block BBOW Bulging Bag of Waters BBO2 Blowby oxygen BC base curve BCC bowel care of choice BCG ntermi Calmette-Guerin BCP birth control pills BD base down BDR background diabetic retinopathy BE bacterial endocarditis BF bifocal B.F. Breastfeed BG Blood gas or blood glucose B.I. brain injury bid twice a day BIL bilateral B/LE bilateral lower extremities Bili, D/I bilirubin, direct/indirect BIO binocular ntermit ophthalmascopy BiVAD biventricular assist device BKA below the knee amputation bl cult blood culture BLE Bilateral upper extremities blood type B,O,A,AB BLS basic life support b.m. bowel movement BM breastmilk BMA bone marrow aspiration BMP basic metabolic panel BMR basal metabolic rate BN bronchial neuritis- brachial BNO bladder neck obstruction BNP brain natriuretic peptide BNR bladder neck ressection BO base out BOA born on arrival BOH Born Out of Hospital BOM bilateral otitis media BOW bag of waters (amniotic membranes) BOWI bag of waters intact BP blood pressure BPD borderline personality disorder Bi-D biparietal diameter BPD Broncho Pulmonary Dysplasia (NICU) BPH benign prostatic hypertrophy BPP Biophysical Profile B.R. bathroom b.r. bed rest Brady bradycardia BRAO branch retinal artery occlusion brkfst breakfast Bro brother BRP bathroom privileges BRVO Branch Retional Vein Occlusion B.S. blood sugar BS breath sounds bs bowel sounds BSA body surface area
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
BSC bedside commode BSO bilateral salpingo-oophorectomy BSP bromsulphalein BSTP Brief Strategic Program (MHC) BTB back to bed BTFDC balloon tipped flow directed catheter BTL bilateral tubal ligation BU base up BUE Bilateral upper extremities BUN blood urea nitrogen BVA best visual acuity BVI Blood Volume Indicator BX biopsy C c with C&A Cardiac Apnea Monitor C&S culture and sensitivity C/D cup to disc c/o complains of C/S Cesarean section CW consistent with C1,C2.... first cervical vertebrae, etc. C2o Compliance of last 20% of inspiration Ca calcium CA cancer;carcinoma CABG coronary artery bypass graft CAC California Alcoholism Counselor CACL calcium chloride CAD coronary artery disease CADC California Alcoholism/Drug Counselor CAG closed angle gloucoma CAI carbonic anhydrase inhibitor Cal calorie CAP Child and Adolescent Program CAP-PDT Child and Adolescent Program — Partial Day Treat. CAP/cap capsule,capillary CAPD continuous ambulatory peritoneal dialysis caps capsule CAR conditioned avoidance response CAS cerebral anteriosclerosis cat cateract CAT computerized axial tomography cat OD cararact OD cath catheter,catheterize, catheterization CAVH continuous arteriovenous hemofiltration CB chronic bronchitis CBC complete blood count CBF cerebral blood flow CBG capillary blood gas CBI continuous bladder irrigation CBR complete bed rest CBS chronic brain syndrome;comprehensive biochemical survey CC chief complaint CCC central corneal clouding CCS California Children’s Services CCT computerized cranial tomography CCU cornary care unit CCVS clean catch voided specimen
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
CD chemical dependency CDDP Cisplatin (C is diamminedichloroplatinum) CDH congenital diaphragmatic hernia CDVR California Department of Vocatinal Rehabilitation CEA carcino-embryonic antigen CENT centration CF cystic fibrosis CFT complement fixation test cg centigram CGL chronic granulocytic leukemia CHB complete heart block CHD coronary heart disease CHF congestive heart failure chg change CHI closed head injury CHO carbohydrate chol cholesterol CHOP Cyclopjosphamide, Doxorubicin (Hydroxydaunorubicin), Vincristine (Oncovin®) and Prednisone Chr chronic CI cardiac index CI convergence insufficiency CID cytomegalic inclusion disease CIDS cellular immunity deficiency syndrome CIN cervical intraepithelial neoplasia Circ circulation CIS carcinoma in situ CK creatine kinase CKU communicates knowledge & understanding CL contact lens Cl- chloride CLD chronic lung disease cldy cloudy clr clear CLSL chronic lymphosarcoma (cell) leukemia cm centimeter CMA compound myopic astigmatism CME cystoid macular edema CMF Cyclophosphamide, Methotrexate and Fluorouracil CMGN chronic membranous glomerulonephritis CMM cutaneous malignant melanoma CMV cytomegalovirus CNA Certified Nursing Assistant CNE chronic nervous exhaustion CNS central nervous system CNVM choroidal neovascular membrane C/O complains of CO2 carbon dioxide COAG chronic open angle glaucoma coag coagulation coc cocaine comp compound conc concentrate cond condition Cong congential conj conjunctive
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
cont. continue present medication cons conservator cont continue conv convalescent coop cooperative COPD chronic obstructive pulmonary disease
COTA Certified Occupational Therapy Assistant COU cardiac observation unit CP chest pain C.P. clinical pathway CP&PD chest percussion and postural drainage CPAP continuous positive airway pressure CPC Chest Pain Center CPD cephalopelvic disproportion cpd compound (pharmaceutical) CPE chronic pulmonary emphysema CPK creatine phosphokinase cpm continous passive motion CPR cardiopulmonary resuscitation cps cycles per second CPT Chest Physiotherapy CR chorioretinal CRR conditioned reflex (response) Cr crutches Creat creatinine crani craniotomy CRAO centeral retinal artery occlusion CRF chronic renal failure CRG Cardiac Respiratory Trend Recording CRI chronic renal insufficiency CRNA Certified RN Anesthetist CRP c-reactive protein CRVO central retinal vein occlusion CS central supply C/S cesarean section C-Section cesarean section CSF cerebrospinal fluid CSME clinically significant macular edema CSR corrected sedimentation rate CST Contraction Stress Test CT chest tube CT scan computerized tomographic scan CTM chlortrimeton CTP Cognitive Therapy Program CTRS Certified Therapeutic Recreation Specilist ctx contraction CTX cytoxan CUS cardiac ultrasound CV cardiovascular COST V.A. costovertebral angle CVA cerebrovascular accident CVC central venous catheter CVD cardiovascular disease CVF Confrontation Visuaal Field CVP central venous pressure CVS clean-voided specimen CVVH continuous venovenous hemofiltration CW close watch CWF Chest Wiggle Factor Cx cervix CXR chest X-ray
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
Cyl cylinder Cysto cystoscopy D Diet. Dietary D day D&C dilation and curettage d&i dry & intact D&Q Deep and quiet D.D.S Doctor of Dental Surgery disch. discharge D/LR dextrose in lacted ringer solution D/W dextrose in water D1, D2 first dorsal ntermitt, etc. DAT diet as tolerated dau daughter DB deep breathe DBP diastolic blood pressure DCP Discharge planner DCC Diabetes Care Center ddc Zalcitabine, Mivid ddi Didanosine, Videx Decub Decubitus defib defibrillate, defibrillator Del Rm Delivery Room demo demonstrates DES diethylstilbetrol DERM Dermatology Devel developmental df dorsi-flexon DFE dilated fundus evaluation DHS Department of Health Services DI diabetes insipidus diaph diaphragm dias diastolic DIC disseminated intravascular coagulation DID dissociative identity disorder Diff differential dig stim digital stimulation DIL dilation DIP distal interphalangeal disch discharge disp dispense div divide/division DJD degenerative joint disease D.m. Descemet’s membrane DM diabetes mellitus DME durable medical equipment DNA ntermittent c acid DNR do not resuscitate DRNG drainage DNS deviated nasal septum; D.O. Doctor of Osteopathy DOA dead on arrival DOB date of birth DOE dyspnea on exertion DOI date of injury DOL day of life dopp Doppler DOS day of surgery DOSS Dioctyl sodium sulfo succintae DP dorsalis pedis
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
dr dram DR diabetic retinopathy D.R. Delivery Room Dr. Doctor DRG Diagnostic Related Group DRNG drainage DSD dry sterile dressing DT Diet Technician D/T ntermitte and tetanus DT’s delirium tremens DTR deep tendon reflexes DVO distance vision only DVT deep vein thrombosis DW daily wear DW5 5% dextrose in water DX diagnosis dyt Stavudine, Zerit E E-stim electrical stimulation ea each EBL estimated blood loss EBT early bed time ec enteric coated ECA Ethacynic acid ECC02R extracorporeal C02 removal ECCE extracapsular cataract extraction ECF Extended Care Facility ecf extracellular fluid ECG electrocardiogram ECHO echogram ECMO ntermittent membrane oxygenation ECT electroconclusive therapy ED Emergency Department ed education EDC estimated date of confinement “due date” EEG electroencephalogram EENT eye,ear,nose and throat Eff effacement EFM Electronic Fetal Monitor eg for example EGL eosinophilic granuloma of the lung EH educationally handicapped ej external jugular EKC epidemic keratoconjunctivitis EKG/ECG electrocardiogram elect electrical elix elixir ELP electrophoresis EMBM expressed mother’s breastmilk EMG electromyogram emp employee Emp Cpd Empirin Compound E.M.R. Electronic Medical Record ENDO Endoscopy ENG electronystagmography ENT ear,nose and throat enz enzymes Eo eosinophils EOB edge of bed EOM extraocular movement Epid Epidural
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
Epis Episiotomy Eq equivalent ER Emergency Room ERCP endoscopic retrograde colangiopancreatogram ERM epiretinal membrane ERV expiratory reserve volume ESO emergency standing order ESR erythrocyte sedimentation rate EST electroshock therapy ESU electrostatic unit E.T. Enterostomal Therapist ET esotropia et. And ETA expected time of arrival ETH elixir terpin hydrate ETHcC elixir terpin hydrate with Codeine ETOH alcohol ETT endotracheal tube eval evaluate (ion) EVS Environmental Services EW extended wear EWCL extended wear contact lens ex from exam examination exer exercise exp expiration Exp Time expiratory time Ext external, extract ext cath external catheter ext rot external rotation extub extubate F F female Fun. Fundus (Arrow indicates position of fundus in relation to umbilicus) FANS Food and nutrition services F.D. fetal demise F.E. fat embolism f/u follow up f.a. fatty acid F.A. fluoroscein angiogram FA folic acid Fa Father FBD functional bowel disease FBS fasting blood sugar FC finger counting FD fixation disparity FDA Food and Drug Administration FDBM Fresh Donor Breast Milk Fe iron FECG Fetal Electrocardiogram (Abd FECG = Abdominal FECG; Int FECG = Internal FECG) FeSO4 Ferrous Sulfate FEV forced expiratory volume FF fundas firm FFA free fatty acid FFP fresh frozen plasma FH family history FHR fetal heart rate
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
FHR var Fetal Heart Rate Variability FHT fetal heart tones FHx family history FI02 % of inspired oxygen Filt filter FIM Functional Independence Measure fl fluid fl ext fluid extract FLM Fetal Lung Maturity fluoro fluoroscopy Fltg Floating (refers to station) FM Fetal Movement F.O.B. foot of bed FOB Father of Baby FOC fellow-on-call freq frequent FS frozen section FSBG finger stick blood glucose FSE fetal scalp electrode FSH follicle stimulating hormone FSP fibrin-fibrinogen split products ft foot f.t. finger tip FT full term FTI free thyroxine index FTKA failed to keep appointment FTND full term normal delivery FTP Failure to Progress FTRR free time room restriction FU follow-up FUO fever of undetermined/unknown origin FWB full weight bearing FWW front wheeled walker FX fracture G Gl. Glaucoma G Gravida G-CSF Filgrastim (Camptosar®) G-tube gastric tube G6PD glucose 6 — phosphate dehydrogenase GA gestational age GABHS group A beta-hemolytic streptococcus Gal gallon GB gallbladder GBS gallbladder series GC gonorrhea GD grave disability GDM gestational diabetes mellitus Gest gestation/gestational Gem Gemcitabine (Gemzar®) GERD gastroesophageal reflux disease GF glomerular filtrate Gfa Grandfather GFR glomerular filtration rate GGT gamma glutamyl transpeptidase GH growth hormone, anterior pituitary GHD growth hormone deficiency GI gastrointestional Glob globulin GLT Guerney Lift Tub Gm Gram
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
GM-CSF Sargramostim (Leukine®) Gm% grams per hundred ntermitten of solution gm% gram per cent gm/dl gram per deciliter Gma Grandmother GOC Guidelines of Care Gonio gonioscopy GOT glutamic oxaloacetic transaminase GP general paresis GPC giant papillary conjunctivitis GPCL gas permeable CL GPT glutamic pyruvic transaminase GR grade GRC Grossmont Rehabilitation Center GSD glycogen storage disease GSW gunshot wound GT gait training GTH gonadotropicc hormone GTT glucose tolerance test gtt(s) drops GU genitourinary GYN gynecological H H/G hygiene and grooming H&H hemoglobin and hematocrit H&P history and physical H,HR hour HZ Hertz H20 water H202 hydrogen peroxide HA headaches HASCV Hypertensive arteriosclerotic cardiovascular disease HASHD Hypertensive arteriosclerotic heart disease HB heart block HBC beta hydroxybutryic dehydrogenase HBIG hepatitis B immune globulin HBP high blood prssure HbsAG hepatitis B surface antigen HC Hydrocortisone HCA Health Care Associate HCCVD hypertensive cardiovascular disease HCG human chorionic gonadotropin H.C.L. hard contact lens Hct hematocrit HCVD Hypertensive cardiovascular disease HDN hemolytic disease of the newborn HEENT head,eyes,ears,nose,throat hem hemorrhage hema hematology Hemi hemiplegic HEP home exercise program HFFI High Frequency Flow Interrupter Ventilation HFLA High Frequency Low Amplitude HFOV High Frequency Oscillatory Ventilation HFV High Frequency Ventilation Hg mercury Hgb hemoglobin HGB, HgB Hemaglobin
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
HGH human growth hormone HH hollenhorst plaque H.H. Home Health HHA hand held assist HI homicidal ideation Hi Cal high calorie Hi protein high protein HIT hypertrophic infiltrative tendinitis HIV Human immuno deficiency virus HL hypermetropia latent HLP hyperlipoproteinemia HM hand motion HMF Human Milk Fortifier HMD hyaline membrane disease HMSAS hypertrophic muscular subaortic stenosis HNP herniated nucleus pulposa HNSHA hereditary nonspherocytic hemolytic anemia HOB head of bed hosp hospital hpf per high power field HPI history of present illness HPVD hypertensive pulmonary vascular disease hr hour H.R. heart rate HR hypertensive retinopathy HRVO hemi-retinal vein occlusion HS/hs hour of sleep HT hypertension ht height HTN hypertension HUS head/cranial ultrasound husb husband HV hyperventilation HVD hypertensive vascular disease HX history hyperal hyperalimentation I I Time Inspiratory Time I&D incision and drainage I&O intake and output IABP intra-aortic balloon pump IADH inappropriate antidiuretic hormone IASD interatrial septal defect IBD inflammatory bowel disease IBI intermittent bladder irrigation IBW ideal body weight I.C. Interim Care IC intracutaneous ICCE intracapsular cataract extraction ICF intracellular fluid I.C.F. Intermediate Care Facility ICP intracranial pressure ICS ntermittent space ICU Intensive Care Unit ID Infectious Disease IDDM insulin-dependent diabetes mellitus IDM infant of diabetic mother IDT Interdisciplinary team ie that is IET infantile estropia IgA immunoglobulin gamma globulin A
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
IgA, IgC, immunoglobulinA Immunoglobulin C IgE immunoglobulin gamma globulin E IgG immunoglobulin gamma globulin G IgM immunoglobulin gamma globulin M IH infectious hepatitis IHD ischemic heart disease IHO idiopathic hypertrophic osteoarthropathy IHP idiopathic hypoparathyroidism IHSS idiopathic hypertrophic subaortic stenosis IJ internal jugular IK interstitial keratitis IL-2 Aldeleukin (Proleukin®) ILM internal limiting membrane I.M. internal medicine IM intramuscular IMA internal mammary artery immune immunization IMO increased medical observation IMP scale inpatient multidimensional psychiatric scale IMV intermittent mandatory ventilation INO Inhaled Nitric Oxide INR international normalized ratio in situ in position In trot internal rotation incr increase IND OPH Indirect Ophthalmoscopy Ineff ineffective inf inferior info information ING Indwelling Naso-Gastric INH Isoniazid Inh Th inhalation therapy Inj inject, injection Inpt inpatient insp inspiration int intermittant INVOL involuntary I/O intake and output IOFB intraocular foreign body IOL intra ocular lens IP Interim Permit IPPB intermittent positive pressure breathing I.Q. intelligence quotient IRBBB incomplete right bundle irreg irregular IRV inspiratory reserve volume IS Incentive Spirometer ISC Servo Control ISH icteric serum hepatitis IUD intrauterine device IUFB intrauterine foreign body IUFD intrauterine fetal demise IUGR intrauterine growth retardation IUP intrauterine pregnancy IUPC Intrauterine pressure catheter IV intravenous IVC intravenous cholangiogram I.V.C. inferior vena cava IVCD intraventricular conduction defect/delay IVF in-vitro fertilization IVH intraventricular hemorrage
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
IVP IV push IVPB intravenous piggyback IVSP interventricular septal defect IWMI inferior wall myocardial infraction J J-P Jackson-Pratt J-tube jejunostomy tube jug jugular JVD jugular venous distension K Kera. Cornea or keratometry K potassium K.A. units King-Armstrong units K2PO4 potassium phosphate kcal kilocalorie KCL potassium chloride
KCLO4 Potasium perchlorate kg kilogram km kilometer KP keratic precipitates KPE kelman phacoemulsification kv kilovolt KVO keep open (I.V.) kw kilowatt kw-hr kilowatt-hour L L left L liter L and A light and accommodation L# lumbar level # 1-5 L-S lumbosacral L/min liters per minute L/S Lecithin-Sphingomyelin Ratio L1, L2, L, first lumbar ntermitt, etc., etc., etc., la left arm LA left atrium Lab laboratory Lab Tech blood drawing technician Lac laceration LAC Long arm cast LAD left anterior descending LAH left atrial hypertrophy LAO left anterior oblique LAP Leukocyte Alkaline Phosphatase LAT left anterior thigh lat lateral lax laxative Lb pound LB lower body LBBB left bundle branch block LBP lower back pain LCS low constant suction LCSW Licensed Clinical Social Worker LD-LUOQ Injections sites (left LDH lactic dehydrogenase LDL low density lipoprotein LDR Labor & Delivery Room LDRP labor,delivery,.recovery/post partum l.e. left eye
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
L.E. lower extremity LE lupus erthematosus LEA lumbar epidural anesthesia LED lupus erythematosus disseminatus LEEP loop electrosurgical excision procedure LES lower esophageal sphincter LEX last eye exam LFT liver function test LG left gluteal Lg large LGA large for gestational age LH luteinizing hormone LHF left heart failure LHRH leuteinizing hormone-releasing hormone Li lithium LiCO3 Lithium Carbonate lipo lipoprotein liq liquid LIS low intermittent suction LK lamellar keratoplasty LKS liver, kidney, spleen LL left lateral LLB long leg brace LLC long leg cast LLLid left lower lid LLL left lower lobe LLQ left lower quadrant LM left main L.M.L. left mediolateral (episiotomy) LMNL lower motor neuron lesion LMP last ntermitt period Lo Na low sodium Lo Res low residue LOA left occiput anterior l.o.c. level of care lax.o.c. laxative of choice LOC level of consciousness LOP left occiput posterior LOS length of stay L.P. light perception LP lumbar puncture LPI laser peripheral iridectomy LPN Licensed Practical Nurse LPr light projection LPT Licensed Psychiartic Technician LTCCS low transverse cervical c-section L.R. labor room LR lactated ringers Lat rec. lateral rectus LS lung sounds LSA lymphosarcoma LSA/RCS lymphosarcoma-reticulum cell sarcoma LSK liver,spleen,kidney LSR lung sounds ratio LTH luteotropic hormone LTKA left total knee arthroplasty LTP laser trabeculoplasty LTV Long Term Variability LUD Left Uterine Displacement LUE left upper extremity l.u.l. left upper lid
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
LUL left upper lobe Lutq lower uterine quadrant LUS left upper segment LV left ventricle LVE left ventricle enlargement LVF left ventricular failure LVH left ventricle hypertrophy LVI left ventricular insufficiency L.V.N. Licensed Vocational Nurse lymphs lymphocytes lytes electrolytes M m minimum M male mo. Month My. Myopia mur. Murmur m dist as directed M&N mydriecyl and neosynephrine M+AM myopic astigmatism M.G. Myasthenia Gravis M/mm3 million per cubic millimeter M.A. Master of Arts MA milliamps mac. Macula MAC minimum apical clearance M.A.C. monitored anesthesia care macro macrocytosis MAD major affective disorder MAE moves all extremities mag sulf magnesium sulfate mag cit magnesium citrate m.a.p. mean arterial pressure MANP megablastic anemia of pregnancy M.A.P. Mean Airway Pressure MAS mobile arm support MAX maximum max maximal MBD minimal brain dysfunction MBM mother’s breastmilk MBS modified barium swallow MC myocarditis MCD medullary cystic disease mcg microgram MCH mean corpuscular hemoglobin MCHC mean corpuscular hemoglobin concentration MCHgb mean corpuscular hemoglobin MCP metacarpal phalageal joint MCV mean corpuscular volume MD Doctor MDI metered dose inhaler Mec Meconium med medial MED medical; medicine; medication mEq milliequivalents MF multifocal MFCC Marriage/Family Child Counselor mg milligram Mg% milligrams per hundred milliters of solution mgmt management
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
MGN membranous glomerulonephritis M.H.C. Mental Health Center MHC Mental Health Counselor MHW Mental Health Worker m.i. modified independence MI myocardial infraction MICN Mobile Intensive Care Nurse micro microcytosis MICU Medical Intensive Care Unit Min minute, minimal, minium MIO monocular indirect ophthalmascopy Misc miscellaneous mixA mixed astigmat mixt mixture ml milliliter mL milliliter ML Midline (episiotomy) mls milliliter MM malignant melanoma mm millimeter mm/hr millimeters per hour mm3 cubic millimeter MMF maximal midexpiratory flow mmHg millimeters of mercury MMPI Minnesota Multiphasic Personality Index mn midnight M.S.N. Masters in Nursing M.O.B. Mother of Baby Mo/M mother Mod moderate M.O.M. milk of magnesia Mono monocyte MOPP Mechlorethamine, Vincristine (Oncovin®), Prednisone, Procarbazine mp as directed/as prescribed MPD multiple personality disorder MPF methylparaben free MPI Maximal Point of Impulse MPP Med Psyche Program m.r. manifest refraction MR medial rectus M.R. mitral regurgitation MRI magnetic resonance imagry MRp macula reflex present MRx1 may repeat times one MS multiple sclerosis ms mitral stenosis MSE mental status examination MSOF multi-system organ failure MSW Masters in Social Work mtg meeting MTHFR methylene tetrahydrofolate reductase mv millivolt M.V.A. motor vehicle accident MVH Mesa Vista Hospital MVP mitral valve prolapse MVR mitral valve replacement MVV maximum voluntary ventilation MxA mixed astigmat myd mydriacyl myelo myelocyte
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
N N near N&V nausea and vomiting N/A not available;not applicable N/C no complaints N/G nasogastric N/S normal saline Na sodium N.A. Narcotics Anonymous NA Nursing Assistant Na+ sodium NAB no acute bleeding NaCl sodium chloride NAD no acute distress, no active disease NAG narrow angle glaucoma NaHC03 sodium bicarbonate NANDA North America Nursing Diagnosis Association NAOP no apparent ocular pathology NB newborn NBQC narrow based quad cane NBT ntermi blue tetradrozoline—white NBTE nonbacterial thromboticendocarditis nc no complaints NC nasal canula n.c. noncompliant NCA neurocirculatory asthenia NCNCA normochromic normocytic anemia NCP blood cell test NCPAP nasal continuous positive airway pressure NCT non contact tonometry NDF no disease found NEC necrotizing entercolitis NEG negative NEO neosynephrine neuro Neurology/Neurological/neurologic Neut neutrophil NF nonfasting NG nasogastric NH4Cl ammonium chloride N.I. No Information NICU Neonatal Intensive Care Unit NIDD non-insulin dependent diabetic NIL not in labor NKA no known allergies NKDA no known drug allergies Nl normal NLP no light perception NM Nurse Manager NNP Neonatal Nurse Practitioner NNS Neonatal Nurse Specialist No number Noc night non rep do not repeat NOU no off unit N.P. neuropsychiatric NP nasopharyngeal NPC near point of convergence NPH neutral protamine Hagerdorn (insulin) NPN nonprotein nitrogen N.P.O. nothing by mouth Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
NR nonreactive NRA negative relative accommodation NRP Neonatal Resuscitation Program N.S. neurosurgery NS nuclear sclerosis Nsg.S. nurses station Nsg nursing NSR normal sinus rhythm NSS normal saline solution NST nonstress test NSU non-specific urethritis NSVD normal spontaneous vaginal delivery Nsy nursery NT not tested NTE Neutral Thermal Environment NTE Not To Exceed NTG nitroglycerin Nutr nutritional NV neovascularization NVD neovascularization at disk NVHD nonvalvular (heart) disease N.V.D. Normal Vaginal Delivery NVE neovascularization elsewhere NVO near vision only NWB non-weight bearing O O oral o/c open crib O&P ova and parasites O.D. Doctor of Optometry O2 oxygen O2 Cap Oxygen capacity O2 Sat Oxygen saturation OA osteoarthritis O.B. obstetrics Obl oblique OBS organic brain syndrome Obs. Observation Oc Bl occult blood occ occasional OCT oxytocin challenge test O.D. overdose o.d. right eye ODM ophthalmodynemomtery OHT ocular hypertension Ohx ocular history oint ointment OM otitis media,obtuse marginal OMD ocular muscle dystrophy OMPA otitis media, purulent, acute ONC oncology ONH optic nerve head OOB out of bed OOP out on pass OP outpatient op operation OPD outpatient department Ophth ophthalmascopy OPV outpatient visit OR operating room
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
ORIF open reduction and internal fixation Ortho orthopedics o.s. left eye osteo osteomyelitis OT occupational therapy OTC over the counter OTR Occupational Therapist, Registered OTS Occupational Therapy Student o.u. both eyes outpt outpatient OZ optic zone oz. ounce P p pulse P C/S Primary Cesarean Section P&A percussion and auscultation P-A pernicious anemia P-CON permanent conservatorship P-para number of pregnancies over 20wks gestation P04 phosphate P2 Pulmonic second sound PA pulmonary artery
PA02 Pressure Arterial Oxygen PABA para amion benzoic acid PAC premature atrial contraction PACU Post Anesthesia Care Unit PAES Pre-Anesthesia Evaluation Services PAFIB ntermitte atrial fibrillation PALM Premature Accelerated Lung Maturity PAM potential acuity meter PAP (smear) Papanicolauno smear pap. Smear papanicolaou cytologic examination Para paraplegic Paracent. Paracentesis PAS para-aminosalicylic acid pas peripheral anterior synechiae PAT paroxysmal atrial tachycardia PAWP pulmonary artery wedge pressure pb posey belt PB Phenobarbitol PBI protein bound iodine PBK pseudophakic bullous keratopathy PBZ pyribenzamine PC peripheral curves PC posterior capsule or posterior chamber pc after meals; after meals PC02 pressure carbon dioxide (arterial) P.C.A. patient controlled analgesia PCA post-conceptual age PCCU Post Cardiac Care Unit PCEA Patient Controlled Epidural Analgesia PCF prothrombin conversion factor PCG Pneumocardiogram PCIRV pressure controlled inverse ratio ventilation PCL posterior cruciate ligament PCN Penicillin P.C.P. primary care physician
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
P.C.V. packed cell volume P.V. polycythemia vera PC+-+WP pulmonary capillary wedge pressure PD Parkinson’s Disease P.D. ntermitt distance PDA posterior descending artery P.D.A. Patient Ductus Arteriosus PDL phoria distance lateral PDR physician’s desk reference PDS polydioxanone suture PDV phoria distance vertical PE physical examination; pulmonary embolism ped pedal PEDS pediatrics
PEEP positive end expiratory pressure PEF peak expiratory flow PEG percutaneous endoscopic gastrostomy PEG pneumoencephalography PEK ntermitt epithelial keratopathy PEO progressive external ophthalmoplegia per through; or by; for each peri Perineal/perineum PERLA pupils equally reactive to light and accommodation PERRLA pupils equal, round and reactive to light & accommodation PFC patient focused care
Pf plantar flexion
PFFWW platform front wheel walker
PFS Patient/Family Services
PGH Pituitary growth Hormone pH acid base pH symbol for hydrogen ion concentration PHA phenylalanine Pharm.D. Doctor of Pharmacy Ph.D. doctorate phos phosphorus PHP Partial Hospitalization Program P.I. Performance Improvement PI peripheral iridectomy p.i. present illness PID pelvic inflammatory disease PIE Pulmonary Interstitial Emphysema PIH Pregnancy Induced Hypertension Ping pinguecula p.i.j. proximal interphalangeal joints PIP peak inspiratory pressure PIPIDA N-para-isopropyl-acetanilide-iminodiacetic acid PIR Problem/Intervention/Response Pit Pitocin PIV Peripheral IV PK penetrating keratoplasty PK pyruvate kinase
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
PKU phenylketonuria Pl plane PLOF prior level of function plt platelet pm afternoon PMA progressive muscular atrophy PMD progressive muscular dystrophy PMH past medical history pmi point of maximal impulse PMIt Post myocardial infarction tachycardia PMN polymorphonuclear neutrophil PMP prior ntermitt period PMS premenstrual syndrome PNC pre-natal care PND paroxysmal nocturnal dyspnea pneum. Pneumonia pneumo. Pneumothorax PNF proprioceptive neuromuscular fasciculation PNH paroxysmal nocturnal hemoglobinuria PNS peripheral nervous system po by mouth po2 partial pressure of oxygen POAG primary open angle glaucoma POD postoperative day POH presumed ocular histoplasmosis poik poikilocytosis polychr polychromasia pop popliteal pos positive post posterior post-op postoperative P.P. postpartum PPD purified protein derivative (tuberculin) PPH primary pulmonary hypertension PPHN persistant pulmonary hypertension of the newborn PPM permanent pacemaker PPP test protamine paracoagulation phenomenon p.prand postprandial PPROM prolonged premature rupture of membranes PPV positive pressure ventilation PRA positive relative accommodation PRBC packed red blood cells PRC packed red cells PRE progressive resistive exercise pre voc pre-vocational Precip Precipitous Delivery preop before surgery Pres presbyope PRI Pain Rating Index Primip primipara priv privileges Prn as needed P.R.N. Pain Resource Nurse pro-time Prothrombin Time ProGran pro granulocyte prom passive range of motion P.R.O.M. premature rupture of membranes PRU Physical Rehab Unit P.S. posterior synechiae
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
PS pressure support PSA polysubstance abuse PSC post subcapsular cataract PSCU Perinatal Special Care Unit PSP phenolsulfonphthalein PSRT photostress recovery time psych/psy Psychiatric/psychological PT Physical Therapy pt patient PTA prior to admission PTCA percutaneous transluminal coronary angiolplasty PTD permanent total disability PTH posttransfusion hepatitis PTL Preterm Labor PTSD post traumatic stress disorder PTT partial thomboplastin time PTV posterior tibial vein PU peptic ulcer PUD peptic ulcer disease pulm. Pulmonary pulv pulverize PUW pick-up walker PV polycythemia vera PVC premature ventricular contraction PVD posterior vitreous detachment PVR proliferative vitreoretinopathy PVR pulmonary vascular resistance PWB partial weight bearing pwd powder PWI posterior wall infarction px prognosis PZI protamine zinc insulin Q q every q15 observed every 15 minutes q2h, q3h, etc. every two hours, every three hours, etc. QA Quiet Area QA Quality Assessment qa.m. every morning qh every hour qid four times per day QR Quiet Room QRS ventricular complex QS quantity sufficent qt quart QUAD quadriplegic quad quadrant qual qualitative quant quantitive R R respiration R C/S Repeat Cesarean Section R/ resistant R/O rule out R/T related to RA rheumatoid arthritis R.A. room air RAO right anterior oblique RAS renal artery stenosis RA test rheumatoid arthritis test
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
RAT right anterior thigh RBBB right bundle branch block rbc red blood cell RBC red blood count RCA right coronary artery RCP Respiratory Care Practitioner RUOQ right upper outer quadrant rd right deltoid RD retinal detachment R.D. Registered Dietician RDS respiratory distress syndrome r.e. regional enteritis RE right eye rect. Rectal Re-ed re-education re: regarding rec’d received recep reception recog recognition ref referral/referred reg regular rehab rehabilitation rept repeat req request res residue Resid residual Resp respiration RET retinoscopy ret returned retic reticulocyte RF rheumatoid factor RG right gluteal RGP rigid gas permeable Rh Rhesus blood factor RHD Rheumatic heart disease RHF right heart failure RIA radioimmune assay RK radial keratotomy RL ringers lactate RLF retrolental fibroplasis RLL right lower lobe RLQ right lower quadrant rm room RML right middle lobe RN Registered Nurse R/O rule out ROA right occiput anterior R.O.M. range of motion R.O.P. retinopathy of prematurity ROP right occiput posterior ROS review of systems R/O S. rule out sepsis RPR Rapid Plasma Reagin (serology test for syphilis) RPT Registered Physical Therapist rpt repeat R.R. recovery room RR respiratory rate RSD reflex sympathetic dystrophy RSO right salpingo-oophorectomy RT Recreational Therapy rt right
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
r.t. right thigh R.T. Respiratory Therapist R. to related to RTKA right total knee arthroplasty RTAR Recreation Therapy Assistant RTC Residential Treatment Center RTF Residential Treatment Facility RTO return to office RTR Recreational Therapist Registered r.u.e. right upper lid RUL right upper lobe RUE right upper extremity RUQ right upper quadrant RVAD right ventricular assist device RVE right ventricular enlargement RVH right ventricular hypertrophy RVR rapid ventricular response RW radiant warmer Rx prescription,treatment,therapy RXN reaction S s without S# sacral level # 1-5 S&F smooth and full S&R seclusion and restraint S/P status post S1, S2 first sacral vertebrae, etc. Sa02 arterial oxygen saturation SAB spontaneous abortion S.A.B. subarachnoid block, spinal anesthetic block SAD seasonal affective disorder SAT saturated SAT% saturation percentage satis satisfactory SB scleral buckle S.B. stillborn SBA standby assistance SBE subacute bacterial endocarditis SBP systolic blood pressure SBR serum bilirubin Subcut subcutaneous SCHIZ schizophrenia SCI spinal cord injury SCL soft contact lens SDCPH San Diego County Psychiatric Hospital single donor platelet pheresis SDPP secl. Seclusion sec second Secr secretions SED sedimentation rate Segs segmented neutrophils sent sentence sev. Severe SFA superficial femoral artery SGA small for gestional age SGOT serum glutamic oxalacetic transaminase SGPT serum glutamic pyruvic transaminase SHA simple hyperopic astigmatism SI suicidal ideation
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
si op sit if it is needed SIADH syndrome ntermittent antidiuretic hormone S.I.C.U. Surgical Intensive Care Unit SIDS Sudden Infant Death Syndrome sig directions for taking SIMV synchronized intermittent mandatory ventilation SIRS systemic inflammatory response syndrome Sis sster SIVP slow intravenous push s.l.k. saline lock S. lens soft lens sl slight SL BIO Slit Lamp Biomicroscopy S.L. sublingual SLB short leg brace SLC short leg cast SLE slit lamp exam SLE systemic lupus erythematosus SLK superior limbic keratitis SLKC superior limbic keratoconjunctivitis SLR straight leg raising sm. Small SM systolic murmur SMA simple myopic astigmatism SMD senile macular degeneration SMON subacute myelo-optical neuropathy SMR submucous resection S.N. student nurse S.N.F. skilled nursing faciliy SNS sympathetic nervous system S.O. standing order SO superior oblique sob stool for occult blood S.O.B. short of breath S.O.C. Standard of Care solu solution solv solvent/dissolve SOM secretory otitis media Sono sonogram SOR spherical over refraction SOS if necessary SP Speech, speech therapy SP 1 Suicide Precautions 1 Sp G specific gravity spans from fingertip to fingertip spec specimen Sph sphere spir spirometry SPK superficial ntermitt keratopathy spont spontaneous sq.cell CA squamous cell carcinoma s.r. sedimentation rate SR superior rectus SRN subretinal neovascularization SRNVM subretinal neovascular membrane SROM spontaneous rupture of membranes SS Social Services SSE soap suds enema SSS sick sinus syndrome
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
ST sinus tachycardia S.T. Speech Therapy Sta station staph staphyloccus STAT immediately; at once STD sexually transmitted disease STG short term goals stim stimulation Strab strabismus strep streptococcus STS serologic test for syphilis STV short term variability subcut. Subcutaneous subj subjective SUD skin unit dose Sup superior supp suppository surg surgery;surgical sus suspension SV stroke volume SV02 mixed venous oxygen saturation SVC superior vena cava S.V.C. sublclavian vein compression SVD sponateous vaginal delivery SVE sterile vaginal exam SVG saphenous vein graft SW social worker SWD short wave diathermy Sx symptoms Sx’d suctioned syr syrum Syr syrup syst systolic sz seizure T T temperature tum. Tumor T&A tonsillectomy aand adenoidectomy T&C type and crossmatch T Con temporary conservatorship T1, T2, etc. first thoracic ntermitt, second, etc. T3 triiodothyronine T4 thyroxine t.a. total assist TA tracheal aspirate tab tablet T.A.B. therapeutic abortion tachy tachycardia T.A.H. total abdominal hysterectomy tal of such, like this TAP applanation tonometry TAS Therapeutic Activity Service TB tuberculosis TBA to be admitted TBLC term birth living child tbsp tablespoon TC tactile cues TCDB turn,cough,deep breath tch teach
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
TCn tetracycline TCRF telephone call received from TD total disability TDF thoracic duct fistula TDx tentative diagnosis TEE transesophageal echocardiography TEF tracheoesophageal fistula temp temperature TENS transcutaneous electrical nerve stimulation Terb Terbutaline tet tox tetanus toxoid Tf trifocal TF tube feeding TG triglyceride TGT thromboplastin generation test THC marijuana Ther Ex therapeutic exercise THR total hip replacement throm thrombosis TIA transient ischrmic attack TIBC total iron binding capacity tid three times per day TIE transient ischemic episode tinc tincture TKE terminal knee extension TKO to keep open TLC triple lumen catheter tm tympanic membrane TM temporomandibular TMJ temporomandibular joint Tmm McKay-Marg tension TNA total nutritient admixture TNS transcutaneous nerve stimulation T.O. telephone order TOCO toco dynamometer TOL tolerate TOLAC trial of labor after cesarean TOP topical TORCH toxoplasmosis, others, rubella, cytomegalovirus, herpes simplex TP total protein TPn total parenteral nutrition TPR temperature,pulse and respirations TR trace T.R. tricuspid regurgitation tr tincture TRAB trabeculectomy trach tracheostomy trans transfer Transp transporter TRH thyrotropin releasing hormone Trit triturate TrTr transfer training Ts Schiotz Tonometry TSH thyroid stimulating hormone tsp teaspoon TSS toxic shock syndrome Tt Touch Tonometry TT tilt table TTFS tissue trauma flow sheet
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
TTN transient tachypnea of the newborn TTWB toe touch weight bearing TUR transurethral resection TURB transurethral resection of bladder TURP transurethral resection of prostate TV tidal volume TVR transcuspid valve replacement TWE tap water enema TX Traction tx treatment U U umbilicus UA urinalysis UAC umbilical arterial catheter UB upper body UBW usual body weight ulc. Col. Ulcerative colitis UC uterine contractions U.C. Urgent Care UCD usual childhood diseases UCG urinary chorionic gonadotropins UE upper extremity UGI upper gastrointestional series UHF ultra high frequency UMB umbilical or umbilicus UMN upper motor neuron ung ointment UO urine output UPI utero placental insufficiency UR Utilization Review URI upper respiratory infection Uro Urology/urological URTI upper respiratory trace infection U/S Ultrasound USN ultrasonic nebulizer USP United States Pharmacopeia ut dict as directed UTI urinary tract infection UV (units) ultraviolet units UVC Umbilical Venous Catheter UVR ultraviolet radiation V v volt VERB verbalize V vitreous V% volume per cent V-fib ventricular fibrillation VA visual acuity VACS vacuoles vag vagina/vaginal VAOD visual acuity right eye VBAC vaginal birth after cesarean section VBG venous blood gas VC verbal cues VCG vectorcardiogram VCU voiding cystourethrogram VD venereal disease VDH valvular disease of the heart VDRL Venereal Disease Research Laboratory (test for syphilis) VDV ventricular and diastolic volume
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
VE vaginal examination Vent ventilator VES velocity erythrocyte sedimentation VF visual field VH vitreous ntermitte VHD vascular heart disease vis visual vit vitamin VMA vanillylmandelic acid VO verbal order voc rehab Vocational Rehabilitation vocab vocabulary VOL voluntary vol volume VS vital signs VSD ventricular septal defect VSS vital signs stable v. tach. Ventricular tachycardia VTP voluntary termination of pregnancy VTX Vertex (presentation of baby) VU verbalizes understanding W w watts W units Wacker units W&D warm and dry w/ with W/D withdrawal w/o without W4D worth four-dot (test for fusion) WA while awake WAC Women’s Acute Care WB whole blood WBAT weight bearing as tolerated wbc white blood cell WBC white blood cell (count) WBQC wide base quad cane W/C wheelchair W.C. Women’s Center wd. Word WFL within functional limits Wk week WM with motion WNL within normal limits WOB work of breathing WP whirlpool WPRC washed packed red cells WPW SYN Wolff-Parkinson White Syndrome WR Wassermann reaction ws watt seconds wt. weight X X exophorin at distance x times X(T) ntermittent exotropia at distance X-match cross match X-ray radiographic test XT exotropia; exotropia at distance Y yr(s) year(s) YAG Yag laser
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
yd yard YO year old
MISC
% percent (H) hypodermic (into subcutaneous tissue) ®(R) abd. right abdomen + and = equal to 1º primary secondary to 2PL Two point leathers 3PL Three point leathers 4PL Four point leathers Increase/increasing Decrease/decreasing
Abbreviations List for use at SCOR, SCVMC, SGH & GPSC – DTD 05/05
Official “Do Not Use” List1
Do Not Use Potential Problem Use Instead U (unit) Mistaken for “0” (zero), the Write "unit" number “4” (four) or “cc” IU (International Unit) Mistaken for IV (intravenous) Write "International Unit" or the number 10 (ten) Q.D., QD, q.d., qd (daily) Mistaken for each other Write "daily"
Q.O.D., QOD, q.o.d, qod Period after the Q mistaken for Write "every other day" (every other day) "I" and the "O" mistaken for "I"
Trailing zero (X.0 mg)* Decimal point is missed Write X mg Lack of leading zero (.X mg) Write 0.X mg MS Can mean morphine sulfate or Write "morphine sulfate" magnesium sulfate Write "magnesium sulfate"
MSO4 and MgSO4 Confused for one another
1 Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.
*Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
Additional Abbreviations, Acronyms and Symbols (For possible future inclusion in the Official “Do Not Use” List)
Do Not Use Potential Problem Use Instead > (greater than) Misinterpreted as the number Write “greater than” < (less than) “7” (seven) or the letter “L” Write “less than”
Confused for one another Abbreviations for drug names Misinterpreted due to similar Write drug names in full abbreviations for multiple drugs Apothecary units Unfamiliar to many Use metric units practitioners
Confused with metric units @ Mistaken for the number Write “at” “2” (two) cc Mistaken for U (units) when Write "ml" or “milliliters” poorly written
µg Mistaken for mg (milligrams) Write "mcg" or “micrograms” resulting in one thousand-fold overdose