Review /Development of
a Regional Abbreviation Policy
1st May 2013
Purpose
In response to the request from the ‘Recording
Care’ Project in the review and development of
an agreed abbreviation policy
Definition:
• An abbreviation (from Latin brevis, meaning short) is a shortened
form of a word or phrase. Usually, but not always, it consists of a
letter or group of letters taken from the word or phrase. For
example, (worryingly), the word abbreviation can itself be
represented by the abbreviation abbr., abbrv. or abbrev.
• In strict analysis, abbreviations should not be confused with
contractions or acronyms (including initialisms), with which they
share some semantic and phonetic functions, though all three
are connoted by the term "abbreviation" in loose parlance
• An abbreviation is a shortening by any method
Literature Review – some key messages
• Care records are comprehensive, accurate, clear and free from
unauthorised abbreviation (Essence of Care, 2010)
• Jargon free, abbreviation free, (RCN, 2010)
• Avoid abbreviations (NMC, 2009)
• Records should be factual and not include unnecessary
abbreviations, jargon, meaningless phrases or irrelevant
speculation.
• The language that you use should be easily understood by the
people in your care.
Lit Review
• To make the system effective, the list would
have to be accompanied by a policy that using a
abbreviation which is not on the list would be a
disciplinary matter (Dimond 2005)
• It is recommended that each healthcare facility
draw up an approved list of abbreviations. The
list should be periodically reviewed and, if
necessary, updated – (An Bord Altranais 2002)
Lit Review
• More than 80 percent of the respondents
supported the creation and adoption of a “do
not use” list. National Patient Safety Goal
http://www.jointcommission.org/standards_info
rmation/npsgs.aspx
• Good practice to use plain English and avoid
the use of jargon or abbreviations whenever
possible - Information Commissioner Officer
(2012) http://www.ico.gov.uk
International
South West Australia (2009) Policy Directive
• Legal requirements
Before using any form of abbreviation, nurses and
midwives must ensure that the abbreviation is
approved in the individual clinical setting. If
there is any doubt, nurses and midwives must
not use any abbreviations and write all words in
full
International
Canada - Self assessment tool
Using abbreviations and symbols appropriately by
ensuring that each has a distinct interpretation
and appears in a list with full explanations
approved by the organization or practice setting
Perspectives:
• Abbreviations: the need for legibility and accuracy in
documentation. Br J Nurs. 2005 Jun 23-Jul 13;14(12):665-6.
• The use of abbreviations in medical records in a multidisciplinary
world--an imminent disaster. Commun Med. 2008 ;5(1):25-33
• Abbreviations and acronyms in healthcare: when shorter isn't
sweeter. Kuhn IF. Pediatr Nurs. 2007 Sep-Oct; 33(5):392-8.
Initiative - Aim
To regionally agree a way forward in the
use of abbreviations by
nurses and midwives in the first instance
with an aim to agree a regional policy for
acceptance and endorsement through the office
of Chief Nursing Officer
Objectives
• To identify existing practice in relation to the use
of abbreviations
• To develop high level principle statements in the
use of abbreviations in record keeping practice
• To develop policy advice in attaining/
maintaining acceptable standards of use of
abbreviations in practice
contd
• To identify and agree a standard, approved
abbreviations list
• To incorporate the agreed list into the Regional
Health and Social Care Nursing Document
• To review abbreviation approach in Maternal
Hand Held Record.
Record Keeping Audit
Initiative Plan
• Terms of Reference agreed
• Work-Plan drafted and agreed
• Membership – Expert Reference Group
established
Terms of Reference
• TOR 1 To agree the initiative plan and
timescales for the project
• TOR 2 To contribute to the achievement of the
initiative aims and objectives
• TOR 3 To undertake ongoing monitoring of the
initiative against the planned activity
TOR contd
• TOR 4 To agree a mechanism of progress
reports from the Project Lead to Recording Care
Group
• TOR 5 To contribute to the agreed policy and
report for submission to the DHSSPS
Note:
• The Expert Reference Group will meet on approximately 3 occasions.
• Membership of Expert Reference Group is non-transferrable except in
exceptional circumstances and with prior agreement of the Chair.