Trying to save time by using abbreviations? Make sure that you aren't putting yourself or your patients in jeopardy.
Nurses are supposed to be communicators, especially when documenting patient information. But if what you write doesn't communicate, then you've failed in your professional and legal responsibilities. Furthermore, you've failed your patient and employer, thereby putting all at risk.
When documenting, it's imperative that you don't put your patient's life at risk because of the methods you use for the task. These methods include the use of abbreviations. The indiscriminate use of abbreviations can be extremely dangerous to you and your patient, besides being a major waste of time.
In this article, I'll tell you how to use abbreviations appropriately. First, let's review the reasons why you should avoid abbreviations.
- Abbreviations can be a total mystery to the reader. If a physician wrote "Patient may get up AFAWG," would he have communicated with you? How much time would you have to spend trying to figure out what he meant? If you and two other nurses looked at this order for 90 seconds each, four and a half minutes of patient care time would have been wasted. Plus you probably still wouldn't have the correct answer.
- Abbreviations are easily confused. Patients are still being overdosed with insulin and heparin because people use "u" for units. Another critical error can occur with the use of "?g," for "microgram," which has been misinterpreted to mean "mg," for "milligrams." Any of these situations could lead to a serious medication error and catastrophic results for the patient. How would you like to write the incident report on the newborn who received ten units of insulin instead of the one unit he was supposed to receive? This type of error automatically multiplies the dosage by a factor of ten.
- Abbreviations that start out as time-savers can end up as time-wasters. As nurses, we typically use abbreviations to speed documentation. But does the reader get our intended message? Ask three nurses what "pt voided qs" means. One might tell you "voiding quantity sufficient" and another one might say "voiding every shift." Try this abbreviation: MSO4. Did you say morphine or magnesium? I have received both answers in every class where I asked the question. The differences in these interpretations could have devastating consequences.
If the doctor wrote "HL the HL," what would you do? Would you know to "heparin lock the Hickman line"? If the aide wrote "300 cc PWISOTF," how much time would you waste finding out it meant "300 cc plus what I spilled on the floor." Yes, it is worth a laugh, but would you laugh if a jury thought the staff was trying to hide something? I've always wondered how long it took that aide to think up the abbreviation.
- The less space you have for documentation, the more inclined you may be to abbreviate. Be extremely careful when using flow sheets, as they're a breeding ground for unapproved abbreviations. The tendency is to force a lot of information into small spaces, thereby avoiding having to document in the progress notes. The results are often creative or imaginative but useless, wasteful, and uncommunicative.
- Abbreviations can cause legal nightmares. What you document must be understandable today and in the future. If you get creative and deviate from the approved abbreviation list, how can you prove what you meant by the abbreviation? Does HA stand for heart attack or headache? At least one nurse has settled out of court because she couldn't answer that question conclusively.
So, when using abbreviations, be extremely careful. Use them as little as possible, stay within the approved abbreviation list, print them carefully, use the appropriate capitalization and periods, and do not get creative. When reading unknown abbreviations, don't guess at their meaning; call the writer for clarification.
If your facility has an approved abbreviation list, take this test. Keep track of the abbreviations you use for a day or two and compare them to the list. I expect that you'll find a significant number of abbreviations that aren't on the list. That approved abbreviation list is designed to ensure that others can read and get the correct message from what you write. If you get creative, how do you know that the reader will get your message? Can you be sure that the reader won't guess wrong, give the wrong care, and under- or overrate the significance of the situation?
If you don't have an approved abbreviation list, be extremely careful and consistent with the abbreviations you use. Stay within the bounds of the lists published in major textbooks. Better yet, get a list approved for your facility.
To get back to the mysterious "Patient may get up AFAWG," the writer meant "Patient may get up as far as the wire goes." The physician who wrote that abbreviation saved himself four seconds, but the nursing staff wasted minutes until they discovered what AFAWG meant. What else could you do with that time? Would your patients' medications get delayed while you attempted to figure out the abbreviation?
Think before you abbreviate
The next time you start to write an abbreviation, think about it. Ask yourself if it is in the best interest of the patient, is the best use of everyone's time, and is the best way for you to discharge your professional duties. The idea behind documentation is communication for the patient's benefit, your protection, and the protection of your facility. If you don't know what an abbreviation means, the writer certainly hasn't communicated, and you waste time trying to get answers. Or you might guess wrong and put the patient in serious jeopardy.
Fay Yocum, MSN, RN has 28 years of experience in civilian and military clinical, educational, and administrative inpatient and outpatient nursing. She is a user and instructor of many nursing documentation formats. Yocum is president of Awareness Productions, a company that provides training in nursing documentation and computer skills. She is also a Lieutenant Commander in the U.S. Navy Nurse Corps Reserves.
Portions of this article appear in her book "Documentation Skills for Quality Patient Care."
Reprinted with permission from Nurses.com.