Abbreviations, charting and malpractice: Be careful what you write

Correct use of medical abbreviations and proper charting are crucial to physician practice.

Issue: February 2007

ByJeffrey R. Wahl, JD

Jeffrey R. Wahl

As a medical malpractice attorney, I have seen hundreds of cases that turned on charting by a physician, nurse or other health care provider. These kinds of cases are problematic for providers and their insurers, because of the collateral “damage” caused by the charting problems.

I have advocated for the use of electronic medical records and so-called “e-prescribing,” in many professional publications. EMRs can minimize numerous human errors, including misinterpretations, erroneous transcriptions and unrecognized medication interactions. Although physicians are notoriously late adopters of non-revenue producing technology, many have begun to migrate to computerized systems, with varying degrees of satisfaction. Until your practice becomes paperless, it is important to review two very important aspects of charting. The first is the Do Not Use list promulgated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); the second is what I call the Improper Notations in the Chart (INC).

JCAHO’s Do Not Use list

Physicians are routinely pressured to see more patients in a day, and the risk of improperly prescribing or committing other written errors grows exponentially. As published in the Institute of Medicine’s groundbreaking report “To Err is Human,” medication errors are among the leading causes of preventable morbidity and mortality in the health care delivery setting.

In 2005, the JCAHO adopted a list of medical abbreviations that cannot be used by any JCAHO-accredited organizations and those seeking accreditation, which also apply to services that have been or are applying to be certified under the Disease-Specific Care Certification Program. The list, which is part of the JCAHO’s 2006 National Patient Safety Goal initiative, is a response to a National Summit on Medical Abbreviations and extensive commentary by the public.

It is likely that many of the readers have had some introduction to the Do Not Use list in their hospital practices. According to the JCAHO, noncompliance with this prohibition remains one of the highest areas of noncompliance found by accreditation surveyors. Since the goals of this list are to reduce medical errors and improve patient safety, it is useful for all of the readers to revisit this list and strongly consider implementing these prohibitions.

Before we review the items on the list and additional abbreviations, acronyms and symbols that may later be incorporated into the list, let’s briefly review the logic behind this list. According to the JCAHO, “the terms on the official ‘Do Not Use’ list have been associated with misinterpretation resulting in medical errors and patient harm. … The requirement to eliminate the use of these terms is a significant and difficult change for many prescribers. Even with the best intentions and efforts, there will be occasional slips. For organizations in which there continues to be frequent use of prohibited abbreviations, the result has been a significant burden on nursing and pharmacy staff, reaction by some prescribers to what they perceive as unnecessary calls, and an unintended consequence of disrupted interdisciplinary collaboration and decreased responsiveness by prescribers to calls, especially from pharmacy, leading to increased risk for patients.” (FAQ 2B for the 2006 National Patient Safety Goals).

The Commission puts the burden of compliance on the medical staff, not pharmacy or nursing, to ensure compliance with the list.

“It is not the responsibility of nurses or pharmacists to manage the behaviors of prescribers. Joint Commission standards assign to the medical staff the responsibility for overseeing the quality and safety of patient care, treatment and services provided by practitioners privileged through the medical staff process and, in particular, providing leadership in activities related to patient safety and improving performance associated with significant departures from established patterns of clinical practice.”

There are essentially five prohibited abbreviations (and derivatives). As stated in the list itself, these prohibitions apply “to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms.”

U (unit): It can be mistaken for a “0” (zero), the number “4” (four) or “cc.” Instead of using the abbreviation “U,” the JCAHO requires substitution with the word “unit.”
IU (International Unit): Has been mistaken for the abbreviation “IV” (intravenous) or the number “10” (ten). Substitute with “International Unit.”
Q.D., QD, q.d., qd (daily); Q.O.D., QOD, q.o.d., qod (every other day): The JCAHO recognized that the “every day” and “every other day” abbreviations have been frequently mistaken for each other, and that a period placed after the “Q” could be mistaken for an “I,” or that the “O” could also be mistaken for an “I.” Instead, the JCAHO requires the words “daily” and “every other day” to be written out completely.
A “trailing zero” (X.0 mg) or lack of a “leading zero” (.X mg): The major issue with these notations is that the decimal point is often missed by the writer or reader. JCAHO did provide one exception for the “trailing zero” prohibition for medication orders or other medication-related documentation: “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.” Instead of the prohibited designation, you should simply leave out the unnecessary trailing zero, and write “X mg” or use the appropriate necessary leading zero, as in “0.X mg” where appropriate.
Medication abbreviations “MS,” “MSO4,” and “MgSO4”: In the first instance, “MS” has been interpreted as morphine sulfate and magnesium sulfate when the other was intended. The other abbreviations have been confused for one another, so they both are prohibited. The required replacement for these abbreviations is to write “morphine sulfate” and “magnesium sulfate” in words, rather than symbols.

In addition to the changes listed above, the JCAHO has provided a list of additional abbreviations, acronyms and symbols that are not prohibited, but could eventually end up on the “Do Not Use” List. It would be wise to consider these to have the same level of prohibition as the ones on the list, and revise your prescribing and charting practices to adopt these changes as well.

“Less than” and “greater than”: write out those terms in words, rather than using their symbols, because they are often misinterpreted as the number “7” or the letter “L.” Even though most of us learned these symbols in elementary school math or science classes, their use continues to create confusion and medical errors among experienced health care providers.
Abbreviations for drug names: similar to the example with morphine and magnesium above, many drug abbreviations are too similar to abbreviations for many other drugs. Instead, you should write in full either the generic name or the trade name of the medication you are ordering or prescribing.
Apothecary units: the use of these units is not universally recognized by all health care providers, and often is confused with metric units. The recommendation is to use metric units instead.
The symbol “@”: while we are all so accustomed to hitting the “SHIFT 2” key on our computers to select the “@” sign for e-mail addresses, in writing, it is often confused with the number “2.” Write out the word “at” instead.
“cc”: this common abbreviation can be confused with the abbreviation for “units” if not clearly written. The recommended alternate is using “ml” or “milliliters.”
Micrograms: when the symbol for micrograms is used, it frequently is misread as “mg” (milligrams), which would cause an overdose by a factor of 1000. Please use the abbreviation “mcg” or write out “micrograms” instead of using the symbol.

Improper draft notations

Medical records have several purposes: to document subjective and objective findings, observations, diagnoses and treatment plans; to assist in providing continuity of care longitudinally; to assist other health care providers who may undertake care of your patient; to satisfy the requirements of Medicare and other payers; and to demonstrate why you did something if your care is questioned by a patient.

After a long night on call, or following an encounter with a particularly annoying or comical patient, you may feel the need to use an “INC” – an Improper Notation in a Chart, which, in my view, should never appear in a chart.

Several issues back, I discussed a patient who sued the radiologist who read her screening mammogram (as negative). I retained a world-class expert who concurred in the negative interpretation of the mammogram, resulting in my radiology client being dismissed from the case. In the same case, the patient sued her family physician, who initially ordered the screening mammogram due to the patient’s age and family history. As previously discussed, the mammogram was correctly interpreted as negative. Everything would have been fine for the family physician if he had left the chart alone.

However, two years later, when the patient had another mammogram which was read as positive, and resulted in the diagnosis of Stage IV breast cancer, the family physician went back to his chart and added his own abbreviation “T.P.G.B.B” on a page just below the order for the initial mammogram. At deposition, the physician testified that he meant “Told Patient to Get Breast Biopsy.” That was curious, because the screening mammogram was interpreted as normal. Once the physician found out that this patient had terminal breast cancer, he got nervous. In an effort to exculpate himself from any potential liability (which was minimal, in the view of the medical and surgical oncology experts involved in the case), he caused the focus of the case to shift from the medical and surgical oncology issues to a record alteration case. Despite the fact that none of this patient’s physicians were liable for medical negligence, she received a substantial settlement because the insurance company could not adequately defend the alteration of the chart with its “INC.”

Not all INCs are that grim. I recommend that no matter how much you may dislike a patient, find the patient’s physical characteristics or demeanor to be humorous, or the patient’s condition to be unusual, you should not “take a shot” at that patient in your chart. Some day, an insurer, attorney, judge or jury might read your abbreviations, which you will have to explain. Some examples of personal abbreviations and other slang from actual charts are:

“Guts and Butts”: your local gastroenterologist
“Chartomegaly”: a patient who is so frequent that he or she has a large, growing medical chart
“CYA”: Cover Your @**, which is an unnecessary prescription or procedure ordered to avoid being sued (the inclusion of which could result in just the opposite!)
“Departure Lounge” or “Death Row”: the geriatric ward of your hospital.
“FLK”: a reference to a “Funny Looking Kid,” often suggestive of characters in the movie “Deliverance.”
“Frequent Flyer”: a patient who is transported to and from the hospital often.
“G.O.M.E.R.”: an acronym for “Get Out of My Emergency Room.”
“HAIRY PSALMS”: a creative acronym, which stands for “Haven’t Any Idea Regarding Your Patient, Send A Lot More Serum.”
“L.O.L. in N.A.D.”: the Little Old Lady in No Acute Distress.
“N.E.T.M.A.”: Nobody Ever Tells Me Anything.
“N.S.A.”: Non-Standard Appearance. Often, this abbreviation refers to what an FLK grows up to be.
“Pumpkin Positive”: a patient considered to be so unintelligent that if you looked into the ear, nose or throat, you would find a brain so small that the entire head would light up.

I hope that this discussion of serious abbreviations and some humorous ones will guide you as you make entries in the charts of your patients.

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Jeffrey R. Wahl, JD, is a health care risk management and liability attorney practicing in Cleveland, Ohio. He has worked with several startup companies involved in health care technology. He can be reached at (216) 308-1401 or by e-mail at jeffwahl@mindspring.com