Avoid Misinterpretations of Abbreviations in Medical Record Documentation

Medical abbreviations and acronyms or “acceptable” terms that physicians and other healthcare professionals generally use in patients’ medical records. Medical transcription service providers make sure that their staff is well-trained in documenting abbreviations, including converting them to their acceptable form when dictated. The benefits of using medical abbreviation while writing notes and drug orders are:

• Convenient
• Saves time
• Allows fitting a word or phrase into a restricted space
• Reduces risk of misspelling words
• Eases communication among physicians and staff
• Improves efficiency

Healthcare staff who read and process the physician’s orders should be familiar with these acronyms and terminologies. Using inappropriate abbreviations and not interpreting them correctly can result in patient harm.  Let’s take a look at expert recommendations on how to avoid misinterpretations of abbreviations in medical record documentation.

Problems Associated with the Use of Medical Abbreviations

Medical abbreviations are used in all medical and surgical departments, during surgery, the emergency room, and at discharge. However, while using medical abbreviations is widely accepted, rampant use and inappropriate abbreviations can result in miscommunication. This will lead to errors in the medical record, especially medication errors, and pose a threat to patient safety. National Medication Error Reporting program run by the US pharmacopeia MedMarx reported that 643,151 medication errors were found by 682 subscribing facilities of which 4.7% (29,974) were attributed to use of medical abbreviations (cited from an article published by StatPearls Publishing LLC, August 2022).

Careless use of medical abbreviations and acronyms in the medical record

• Communication problems: The failure to communicate properly is one of the major reasons for medical errors. Healthcare providers use serious medication abbreviations when writing drug orders. Junior staff are responsible for understanding the abbreviation. However, medical abbreviations can have multiple meanings or contradictory or ambiguous meanings. If junior staff cannot decipher or interpret the abbreviation in the medical chart or a drug prescription, they will be unable to carry out the order (if they cannot clarify it with the physician).
• Can put patient safety at risk: Use of medical abbreviations that can have multiple meanings can lead to further communication lapses and put patient safety at risk. If junior staff misunderstands, misreads, or incorrectly interprets the abbreviation, it can cause serious errors in dispensing or administration of a medication or a test. These issues can delay care and even jeopardize the patient’s safety.
• Specialty-specific concerns: Each medical specialty has its own acceptable terminologies. For instance, a transcription company providing orthopedics transcription services would need to be well-versed in abbreviations used in orthopedic progress/consult notes. However, these speciality specific abbreviations used within a practice may not be recognizable to those not working within the same field.
• Errors in the medical chart: With the widespread adoption of electronic health records (EHR), medical abbreviations are often repeated in the medical chart and will continue to pose risks to patient safety. Moreover, the EHR autocorrect tool which can speed up medical transcription can easily cause errors. Injury attorneys Lowenthal & Abrams cite the example of a patient whose chart said she had presented with “morphine sulfate”, which is a drug, not a symptom. The mistake was found when the attending nurse cross-checked the patient’s outside chart against her medical history – the notation of “MS” which was meant to indicate Multiple Sclerosis was mistaken as morphine sulphate (lowenthalabrams.com).

Common Medical Abbreviation Errors

Every medical chart or a drug prescription in any healthcare institution will have at least one abbreviation per page in the patient’s medical chart, note the authors of the article published by StatPearls Publishing LLC. According to data from National Medication Error Reporting program:

• The three most common types of errors due to the use of medical abbreviations were errors in prescribing, improper dose/quantity and incorrect preparation of the medication.
• The most common medical abbreviation error was the use of QD (once daily), which accounted for 43.1% of all errors. The next was the use of U for units, cc for ml and other decimal errors.
• Use of MS or MS04 for morphine sulfate (mistaken as magnesium sulphate) was the most common drug abbreviation name that led to an error.
• Up to 81% of the errors were found to occur at the time of ordering the medication
• The administration, procurement, and monitoring process was associated with less than 2% of the total errors.

The program also found that errors in medical transcription and in the dispensing area occurred were less frequent.

Here’s a list of common error-prone medical abbreviations, symbols, and dose designations and best practices (www.ismp.org):

l – Liter: Lowercase letter l mistaken as the number 1 – Use L (UPPERCASE) for liter

Ng or ng – Nanogram: Mistaken as mg or as nasogastric – Use nanogram or nanog

IN – intranasal: Mistaken as IM or IV – Use NAS (all UPPERCASE letters) or intranasal

HS – Half Strength: Mistaken as bed-time (hs) – Use half-strength

BIW or biw – 2 times a week: Mistaken as 2 times a day – Use 2 times weekly

IJ – Injection: Mistaken as IV or intrajugular – Use Injection

APAP – acetaminophen: Not recognized as acetaminophen – Use acetaminophen

MgSO4 – magnesium sulphate: Mistaken as morphine sulphate – Use complete drug name

Lack of a leading zero before a decimal point (such as .5 mg) 0.5 mg: Mistaken as 5 mg if the decimal point is not seen – Use a leading zero before a decimal point when the dose is less than one measurement unit

# – Pounds: Mistaken as a number sign – Use lb if referring to pounds

How to Avoid Misinterpretations of Abbreviations in Medical Record Documentation

Though using abbreviations can save time, incorrect interpretation of these abbreviations is unacceptable. Best practices to avoid errors associated with medical abbreviation use:

• Adhere to the standard for the appropriate use of abbreviations and minimum list of dangerous abbreviations, acronyms, and symbols published by the Joint Commission (JC).
• Follow recommendations from the Institute for Safe Medication Practices, which includes:
  • Avoiding abbreviating drug names entirely
  • Being extra careful when abbreviating health syndromes, diseases, and conditions
  • Being alert to problems caused by certain abbreviations, for e.g., B for breast, brain, or bladder.
  • The person who uses an abbreviation must take responsibility for making sure that it is properly interpreted
• Develop a list of approved and not approved medical abbreviations.
• Educate all staff on the dangers of using abbreviations

• Encourage junior staff to communicate with senior staff who write the abbreviations before carrying out the order
• Conduct regular audits to check for compliance
• Disallow use of medical abbreviations on all patient charts, discharge forms, consent forms and prescriptions

Outsourcing medical transcription to an expert can help avoid misinterpretations of abbreviations in medical record documentation. Physicians should choose a company that has trained and experienced medical transcriptionists. These professionals receive special training on abbreviations and acronyms in the medical record, which includes converting error-prone abbreviations to their acceptable form when dictated.