Академический Документы
Профессиональный Документы
Культура Документы
NURSING POLICY
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 1 of 13
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 2 of 13 Page Effected Revision Number
TABLE OF CONTENTS:
SUBJECTS PAGE NO.
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 3 of 13 4
REFERENCES 4 7. ATTACHMENT 1 DO NOT USE ABBREVIATIONS LIST 8. ATTACHMENT 2 APPROVED ABBREVIATIONS LIST
5 7
1. PURPOSE
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 4 of 13
1.1 To provide guidance to health care personnel regarding the use and potential misuse of symbols, acronyms and abbreviations in the patients medical record to eliminate confusion and improve patient care outcome. 2. POLICY 2.1 All physicians orders are carried out and implemented within time frame set forth in this guideline to ensure timeless of care in accord with accepted clinical practice guidelines and care plan. 3. SCOPE 3.1 This policy applies to all Gulf Diagnostic Center Hospital staff and employees. 4. RESPONSIBILITY 4.1 All Staff only Gulf Diagnostic Center Hospital accepted abbreviations may be written on the patients medical records to eliminate confusion and improve clinical efficiency and patient outcomes. 5. GUIDELINES: 5.1 The use of symbols and abbreviations in entries and diagnosis in the patient medical record is discouraged. 5.2 Abbreviations and symbols and/or initials in the patients medical record are not allowed to designate a final diagnosis, surgical operation and procedure or in the completion of an informed consent. 5.3 Abbreviations with multiple meanings should be completely spelled out. 5.4 Only the approved abbreviations are used on the patients medical record. 5.5 The Do Not Use abbreviations list is available on all patient care areas. Orders that use any abbreviations on the Do Not Use list are verified with the attending physician prior to implementation of the order. 6. REFERENCES 6.1 JCIA Standard for Hospital ATTACHMENT 1 DO NOT USE ABBREVIATIONS
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 5 of 13 Preferred Term Write unit Write international unit Write daily and every other day
Abbreviation U (for unit) IU (for International Unit) Q.D., OD, Q.O.D. (Latin abbreviation for once daily or every other day)
Trailing zero (x.0 mg) and lack of leading zero (.x mg)
Potential Problem Mistaken zero, four or cc Mistaken as IV (intravenous or 10 (ten) Mistaken for each other. The period after the Q can be mistaken as I and the O can be mistaken for I Decimal point is missed
MS & MSO4
ug (for Microgram)
Confused for one another. Can mean morphine sulfate or magnesium sulfate Mistaken for mg (milligram) resulting in one thousand-fold dosing overdose. Mistaken for either half strength or hour of sleep (at bedtime.) q.H.S. mistaken for every hour. All can result in dosing error Mistaken for three times a day or twice weekly resulting in an overdose or underdose. Interpreted as discontinue whatever medications follow (typically discharge
Never write a zero by itself after a decimal point (x mg), and always use a zero before a decimal point (0.x mg) Write morphine sulfate or magnesium sulfate or MgSO4 Write mcg or micrograms Write out half strength or at bed time
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 6 of 13
c.c. (for Cubic Centimeter) Zero after decimal point (1.0) for (1 mg)
meds) Mistaken for U (units) when poorly written Misread as 10 mg if the decimal point is not seen Misread as 5 mt.
No zero before decimal point (.5) for 0.5 mg) AU (for Aurio Uterque/Each Ear) AS (for Left Ear) AD (for Right Ear)
Mistaken for OS (left eye) Mistaken for OD (right eye) (for Greater Than Misinterpreted as the < (for Less Than number 7 (seven) or the letter L Confused for one another Abbreviations for drug names Misinterpreted due to similar abbreviations for multiple drugs Apothecary Units/English Units Unfamiliar to many practitioners Confused with metric units @ Mistaken for the number 2 (two) OD Confused for right eye Approved Medical Abbreviation List
Abbreviation Description Abbreviation
Write ml or milliliter Do not use terminal zeros for doses expressed in whole numbers. Always use zero before a decimal when the dose is less than a whole unit. Do not use this abbreviation. Write both ears Write left ear Write right ear Write greater than Write less than Write drug names in full Use metric units Write at Write once daily
Description
Abdnominal Aortic Aneurysm Arterial Blood Gases Abdominal Circumference Alpha Fetoprotein
Bundle Branch Block Bacille Calmette Guerin Base Excess Beta Human Chorionic Gonadotropin
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 7 of 13
Twice a day Blood Pressure Biparietal Diameter Benign Prostatic Hypertrophy Breech Bowel sound Bilateral Salpingo Oohorectomy Blood Urea Nitrogen With Culture & Sensitivity Caesarean section Cervical Vertebrae Calcium Carcinoma/ Cancer Coronary artery Bypass Graft Coronary Artery Disease Capsules Complete Blood Count Common Bile Duct Capillary Blood glucose Controlled Cord Hip Congenital Dislocation Hip Carcinoembryonic Antigen Congenital Heart Disease Congestive Heart Failure Carbohydrate Cholesterol
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 8 of 13
Expected Date of Delivery Electroencephalogram Estimated Fetal Weight Esophagogastroduodenoscopy Electrohydraulic Lithotripsy Enzyme-linked Immunoabsorbent Assay Electromyography Ear, Nose and Throat Endoscopic Retrograde Cholagiopancreatography Dilatation and Curettage ERPC Evacuation of Retained Products of Conception Dehydroepiandrosterone Sulphate ESR Erythrocyte Sedimentation Rate Disseminated Intravascular Coagulation ESWL Extracorporal Shock Wave Lithotripsy Distal Interphalageal ET Endotracheal Tube Diabetes mellitus FB Foreign Body Deoxyribonuceic Acid FBG Fasting Blood Glucose (CAUTION: glucose must be used instead of sugar) Dead on Arrival FD Forceps Degradation Products Digital Subtraction Angiography FDP Forced Expiratory Volume Deep Tendon reflex FEV Fresh Frozen Duodenal Ulcer FFP Plasma Fetal Heart Rate HbS Sickle-cell Hemoglobin Fraction of Inspired Oxygen HbsaB Hepatitis B Surface Antibody Forced Inspiratory Volume HbsaG Hepatitis B Antigen Surface Approved Medical Abbreviation List Femoral Length Fetal Movement French Gauge for Catheters Fetal Scalp Electrode Follicle Stimulating Hormone Fluorescent Treponemal Antibody Absorption (test for syphilis) Fever Unknown Origin Forced Vital Capacity Fracture Gram Primigravida, Secondigravida, etc HBV HC HCG Hct HCV HDL HDV HEENT HGB HGH 5-HIAA Hepatitis B Virus Head Circumference Human Chorionic Gonadotopin Hematocrit Hepatitis C Virus High Density lipoprotein Hepatitis D Virus Head, Eyes, Ears, Nose, and Throat Hemoglobin Human Growth Hormone 5 hydroxy indole acetic acid
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 9 of 13
Human Immunodefeciency Virus Human Lymphocytic Antigen High Power Field Human Papilloma Virus Heart Rate Hysterosalpinggogram Herpes Simplex Virus Human T-cell Lymphotropic Virus High Vaginal Swab History Incision and Drainage Intracapsular Cataract Extrcation Infant of diabetic Mother Impaired Glucose Tolerance Ischaemic Heart Disease Interleukin Large for Gestational Age Luteinizing Hormone Left Iliac Fossa Left Lower Lobe
Approved Medical Abbreviation List IOL IOP IPPV IQ ITP IUCD IUFD IUGR IV IVF IVH IVP JVP kg kj Induction of Labor Intraocular Pressure Intermittent Positive Pressure Ventilation Intelligence Quotient Idiophatic Thrombocytopenic Purpura Intrauterine Contraceptive Device Intrauterine Fetal Death Intrauterine Growth Retardation Intravenous In Vitro Fertilization Intraventricular Hemorrhage Intravenous Pyelogram Jugular Venous Pressure Kilogram Kilojoules LLQ LMP LOA LOP LOS LOT LP LPO LSK LUL LUQ LVF m m RNA MAS Left Lower Quadrant Last Menstrual Period Left Occipital Anterior Left Occipital Posterior Lower Oesophageal Sphincter Left Occipital Transverse Lumbar Puncture Left Posterior Oblique Liver, Spleen, Kidneys Left Upper Lobe Left Upper Quadrant Left Ventricular Failure Meter Messenger RNA Meconium Aspiration Syndrome
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 10 of 13
Mean Corpuscular Hemoglobin Micrograms Mean Corpuscular Volume Doctor of Medicine Milliequivalent Methemoglobin Milligram Menstrual History Myocardial Infarction Milliliter Millimeter Post Coital Test Patient Ductus Arteriosus Positive End Expiratory Flow Rate Peak Expiratory Flow Rate Pupils Equally Reactive to Light and Accomodation
Kidney, Ureter, Bladder Keep Vein Open Lumbar Vertebrae Labour and Delivery Local Anesthetic Left Anterior Decending Corononary Artery Left Anterior Oblique Leukocyte Alkaline Phosphatase
Laparoscopic Assisted Vaginal Hysterectomy
Lactate Dehydrogenase Low Density Lipoprotein Liver Function Test Millimole Molecular weight Magnetic Resonance Imaging Manual Removal of Placenta
Methicillin Resistant Staphylococcus Aureus Approved Medical Abbreviation List Multiple Sclerosis Methicillin Sensitive Staphylococcus Aureus Midstream Specimen of Urine No abnormality Detected Nasogastric Naso Gastric Tube Nothing by Mouth Non- steroidal Anti-inflammatory Drug Normal spontaneous Vaginal Delivery Ova and Parasites On Examination Oxygen Oxygen Saturation Obstetrics & Gynaecology Occipito Frontal Circumference Ovarian Hyperstimulation Syndrome Occipito Posterior Oral Polio Vaccine QNS Ph Ph1 pHa PK PKU PLT PMB PMI PN PO PO2 POC PPD PPH ppt PR PRN Quantity Not Sufficient Hydrogen Ion Concentration Philadelpia Chromosome Arterial PH Phosphate Kinase Phenyketonuria Platelet Postmenopausal Bleeding Point of maximal Impulse Postnatal By mouth/ per oral Partial Pressure of Oxygen Products of Conception Purified Protein Derivative Post Partum Haemorrhage Precipitate Per Rectum As needed
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 11 of 13
Premature Rupture of Membranes Postate Specific Antigen Prothrombin Time Percutaneous Transhepatic Cholagiogram Percutaneous Transcoronary Angioplasty Parathyroid Hormone Partial Thromboplastin Time Pyrexia of Unknown Origin Salpingo-oophorectomy Sacral segments Oxygen Saturation Serum Bilirupin Subcutaneous
PROM PSA
PT
Approved Medical Abbreviation List R/O RAST RBC RBG RDS REM Rh RHD R1 RIA RIF
RLL
Rule Out Radioallergoabsorbent Test Red Blood Cell Random Blood Glucose Respiratory Distress Syndrome Rapid Eye Movement Rhesus Rheumatic Heart Disease Resistance Index Radioimmunoassay Right Iliac Fossa Right Lower Lobe Right Lower Quadrant Right Medio Lateral Ribonucleic Acid Right Occipital Anterior Range of Motion Right Occipital Posterior Respiratory Rate Respiratory Synctial Virus
SGA SGPT SIDS SLE SOB sp gr SPECT SROM Staph STAT STD Strep Supp SVC SVD T&A T1-12 Tab TAH TB
Small for Gestational Age Serum Glutamic Pyrubic Transaminase Sudden Infant Death Syndrome Systemic Lupus Erythematous Shortness of Breath Specific Gravity Single Photon Emission Computerized Tomography Spontaneous Rupture of Membranes Staphlococcus Immediately Sexually Transmitted Disease Streptococcus Suppository Superior Vena Cava Spontaneous Vaginal Delivery
Tonsillectomy and Adenoidectomy
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 12 of 13
Road Traffic Accident Tricuspid Incompetence TI Right Upper Lobe TIA Tricuspid Ischemic Attack Right Upper Quadrant TIBC Total Iron Binding Capacity Right Ventricular Failure tid Three Times Daily Prescription TL Tubal Ligation Tympanic Membranes TPR Temperature, Pulse and Respiration Transcutaneous Nerve Stimulator TRH Thyroid Releasing Hormone Termination of Pregnancy TSS Toxic Shock syndrome Toxoplasmosis, Rubella, TURBT Transurethral Resection of Bladder Cytomegalovirus & Herpes Tumor Trial of Scar TURP Transurethral Resection of the Prostate Treponema Pallidum HAemaglutinating UGI Upper Gastrointestinal Antibody Total Parenteral Nutrition Ung Ointment Approved Medical Abbreviation List Upper Respiratory Tract infection Ultrasound Urinary Tract Infection Ventricular Fibrillation Visual Acuity Venereal Disease Research Laboratory Vaginal Examination Visual Evoked Response Vaginal Hysterectomy Very Low Density Lipoprotein VRE VS VSD Vx WBC WHO WNL WPW x-match Vancomycin Resistant Enterococci Vital Signs Ventricular Septal Defect Vertex White Blood Count World Health Organization Within Normal Limits Wolff Parkinson White Cross match
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]
Policy No: MED-NUR-P0053/12 Issue Date : November 2012 Revision No.: Original 01 Revision Date : Next Revision : November 2014 Page 13 of 13
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Appendix: Yes [ ]
No [ ]