Where might I find the latest list of do not use abbreviations of medical terms for all including OASIS?
If you are Joint Commission accredited you can find the list of do-not-use abbreviations under standard IM.02.02.01 for Home Health. Standard IM.02.02.01 EP 2 states that the healthcare organization must use standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations.
Element of Performance 3 addresses do-not-use abbreviations. It states that the healthcare organization follows its list of prohibited abbreviations, acronyms, symbols, and dose designations, which includes the following:
- Q.D., QD, q.d., qd
- Q.O.D., QOD, q.o.d, qod
- Trailing zero (X.0 mg)
- Lack of leading zero (.X mg)
- Note 1: A trailing zero may be used only when required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
- Note 2: The prohibited list applies to all orders, preprinted forms, and medication-related documentation. Medication-related documentation can be either handwritten or electronic.
CMS regulations are as follows:
§484.55(e) Standard: Incorporation of the OASIS Data Set
OASIS must be incorporated into the HHA's own assessment, exactly as written. Both the language and the groupings of the OASIS items must be maintained. Integrating the OASIS items into the agency's own assessment system in the sequence presented in the OASIS form would facilitate data entry of the items into data collection and reporting software. However, HHAs may integrate the items in such a way that best suits the agency's own assessment
Please check your State requirements and your accrediting organization for rules, regulations and standards that address do-not-use abbreviations.
If your organization adds additional abbreviations to the list of do-not-use abbreviations above, ensure that your staff is following your policy.
ISMP has a list of error prone abbreviations – http://www.ismp.org/Tools/errorproneabbreviations.pdf
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