Standards Australia
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Guide to the use of abbreviations, acronyms and local
terms in healthcare
Part Title:
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Designation:
HB XXX
Part Number:
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Supersedes Standard No: Click here and type Superseded Standard Number
Australian OR Joint:
Australian
Creation Date:
2006-10-09
Revision Date:
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Issue Date:
December 2006
Committee Number:
IT-014
Committee Title:
Health Informatics
Subcommittee Number: IT-014-02
Subcommittee Title:
Health Concept Representation
Project Manager:
Renati Barel/Nick Bradshaw
PM’s Email Address:
Nick Bradshaw@standards.org.au
WP Operator:
Heather Grain/Moya Conrick/Barel
Project Number:
7924
Combined Procedure?: No
Committee Doc No.:
ONE Alpha followed by FOUR numerical (eg: N9999)
Stage:
PRELIMINARY (V0.04 edited on 8 Dec06)
Committee Reps:
Australian and New Zealand College of Anaesthetists
Australian Association of Pathology Practices Inc
Australian Health Insurance Association
Australian Healthcare Association
Australian Information Industry Association
Australian Institute of Health & Welfare
Australian Institute of Radiography
Australian Medical Association
Australian Private Hospitals Association
Central Queensland University
Commonwealth Department of Health and Aging
Consumers’ Federation of Australia
Consumers’ Health Forum of Australia
Department of Health (South Australia)
Department of Health Western Australia
Department of Human Services, Victoria
Engineers Australia
General Practice Computing Group
Health Informatics Society of Australia
Health Information Management Association of Australia
Health Professions Council Of Australia
HL7 Australia
Medical Industry Association of Australia Inc
Medical Software Industry Association
Medicare Australia
National Health Information Management Group
NSW Health Department
Pharmacy Guild of Australia
Pharmaceutical Society of Australia
Queensland Health
Royal Australian and New Zealand College of Radiologists
Royal Australian College of Medical Administrators
Royal Australian and New Zealand College of Obstetricians & Gynaecologists
Royal College of Nursing, Australia
Royal College of Pathologists of Australasia
Society of Hospital Pharmacists of Australia
The University of Sydney
Additional Interests:
HIMMA
La Trobe University
Product Type
Handbook
Document Status
Current
Document Availability
Private
History:
Click here and type history information using shift return for new line
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PREFACE
THIS GUIDE HAS BEEN DEVELOPED IN RESPONSE TO THE INCREASED
PROLIFERATION IN THE USE OF ABBREVIATIONS, ACRONYMS AND LOCAL
TERMS IN HEALTH RECORDS. THE INTRODUCTION OF ELECTRONIC HEALTH
RECORD SYSTEMS WILL REQUIRE ACTIVE MANAGEMENT OF THESE TERMS IN
CLINICAL TERMINOLOGIES.
AS AUSTRALIA MOVES TOWARDS THE
IMPLEMENTATION OF SUCH TERMINOLOGIES THERE IS A NEED TO CLEARLY
IDENTIFY RELEVANT USE ISSUES AND BEST PRACTICE TO BE IMPLEMENTED
IN MANUAL DATA COLLECTION SYSTEMS AND TO SUPPORT THE ONGOING
DEVELOPMENT OF AUTOMATED TERMINOLOGICAL APPROACHES TO SAFE
HEALTH INFORMATION COLLECTION, USE AND COMMUNICATION.
THIS GUIDE IDENTIFIES STRATEGIES AND PROCESSES APPROPRIATE TO THE
MANAGEMENT OF ABBREVIATIONS, ACRONYMS AND LOCAL TERMS IN
HEALTH CARE AND HOW THESE PROCESSES MAY BE INTEGRATED INTO
TERMINOLOGICAL GOVERNANCE SYSTEMS.
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CONTENTS
Page
PREFACE
2
SECTION 1 INTRODUCTION
5
1.1 Preamble 5
1.2 SCOPE
5
1.3 AUDIENCE .......................................................................................................................... 6
1.4 PURPOSE............................................................................................................................. 6
1.5 STAKEHOLDERS ............................................................................................................... 7
1.6 STRUCTURE OF THE GUIDE............................................................................................ 7
SECTION 2 OVERVIEW OF ABBREVIATIONS, ACRONYMS AND LOCAL TERMS
8
2.1 WHAT ARE ABBREVIATIONS, ACRONYMS AND LOCAL TERMS? .......................... 8
2.1.1 Abbreviations .................................................................................................................. 8
2.1.2 Acronyms ........................................................................................................................ 8
2.1.3 Local Term ...................................................................................................................... 8
2.2 WHY ARE THESE CONCEPTS USED SO FREQUENTLY IN HEALTH CARE? ............ 8
SECTION 3 MANAGEMENT PRINCIPLES
10
3.1 INTRODUCTION .............................................................................................................. 10
3.2 Identification of Context ..................................................................................................... 11
3.3 Reference List ..................................................................................................................... 11
3.4 Maintenance Processes ....................................................................................................... 11
3.5 Notification Processes ......................................................................................................... 11
SECTION 4 RELATIONSHIP TO NATIONAL CLINICAL TERMINOLOGY
GOVERNANCE 12
4.1 WHERE DO ABBREVIATIONS, ACRONYMS AND LOCAL TERMS FIT INTO A
NATIONAL CLINICAL TERMINOLOGY? ........................................................................... 12
4.2 STANDARDISED IMPLEMENTATION IN SYSTEMS ................................................... 12
SECTION 5 CONTACTS ON ABBREVIATIONS, ACRONYMS AND LOCAL TERMS
13
5.1 NATIONAL GOVERNANCE ............................................................................................ 13
5.2 DOMAIN GUIDANCE ...................................................................................................... 13
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5.3 GENERAL SYSTEM GUIDANCE .................................................................................... 13
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STANDARDS AUSTRALIA
Handbook
Guidelines for the use of abbreviations, acronyms and local terms in
Healthcare
INTR ODU C T IO N
1.1 Preamble
Abbreviations, acronyms and local terms are often context specific and there are single
abbreviations that have many meanings. The use of abbreviations, acronyms or local terms
that are not clear outside the specific contexts and/ or user domain has resulted in confusion
and in some cases inappropriate patient treatment. Rapid developments in health care and
health research activities often lead to the further proliferation of abbreviations, acronyms
and local terms. This is not a problem if these used for discourse within a specific unit
where their meaning is understood but they become extremely problematic when they are
written or shared outside the local area or domain. However the increasing requirement for
sharing health information has lead to local abbreviations, acronyms and terms moving
outside their perceived audience. This is exacerbated by a mobile workforce and makes the
use of such terms a significant issue for safe, accurate and meaningful communication
across the continuum of health care.
Increasingly these problems are being compounded by the use of Short Message Service
(SMS) language, and generational change in the use of language that is not n ecessarily
understandable by the health workforce as a whole or acceptable in a legal document. This
language is already appearing in health records and has led to indecision as well as
inappropriate or incorrect clinical activities. Words like ‘Akcdnt’ or symbols such as ‘:-(’
and ‘:-)’ are now creeping into these records. Acronyms are also the cause of problems
because they are so abundant and ubiquitous in our language. A more critical situation
arises when there are heteronymous acronyms used in the same industry or area of interest.
This creates new opportunities for error.
This handbook supports the activities of clinicians, information managers and
terminologists. When applied it has the potential for a positive impact on patient safety and
data quality. It promotes safe practice among those who communicate health information to
avoid serious and even potentially fatal consequences of misinterpretation of some
abbreviations, symbols and dose designations used as health data. This handbook will support
the implementation of clinical terminology in a consistent manner.
1.2 SCOPE
This handbook identifies principles and processes relevant to the governance of
abbreviations, acronyms and local terms in health information and health information
systems.
This includes abbreviations, acronyms or local terms found in health records, electronic or
paper based. Where necessary standard abbreviations should be used to support safe
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healthcare and communication in order to improve patient safety by eliminating the
misinterpretation of concepts, which may result in adverse events.
This handbook acknowledges that the development of terminological governance standards
are still in their infancy and supports these activities.
Details of specific abbreviations, acronyms and local terms and their use are not included,
however examples of different types and use environments have been identified.
Minimise use of abbreviations, acronyms and local terms.
Electronic systems don’t need to use abbreviations, acronyms and local terms.
1.3 AUDIENCE
Intended users of the handbook include:
(a)
Contributors to health records who may wish to use new abbreviations or to clarify
the meaning of existing abbreviations, acronyms and local terms in a given context;
(b)
Users of health records who need to understand the meaning of an abbreviation,
acronym or local term in a given context;
(c)
Information custodians: people responsible for managing and maintaining the records.
(d)
Clinical terminology governance organisations, including professional groups w ho
will need to incorporate abbreviation, acronym and local term management activities
into interface terminology representation systems and to be able to identify the
context in which the abbreviation, acronym or local term is used, if it is to be
correctly associated with a unique health concept.
(e)
System developers who are seeking knowledge of the process and principles of the
use of abbreviations, acronyms and local terms in their products, on screens, reports
or other forms of information collection or dissemination mechanisms. This guide
will help them to design safer systems and encourage the use of consistent approaches
to terminology in health care. It is also envisaged that this group will find this guide
of use in developing strategies and systems to interface with clinical terminology
service products;
The principles and methodology included in this guide are universally applicable, that is
they are appropriate in a manual or a computerised environment. Where there are rare
differences in requirements for computerised clinical terminologies these are clearly
identified.
1.4 PURPOSE
This guideline identifies the issues and best practice in managing abbreviations, acronyms
and local terms, and their creation, use and presentation in a health record environment.
Healthcare workers, due to their workload, are major users of this type of short hand
concept documentation. This approach to concept representation and communication leads
to misinterpretation of data instructions, and consequently poor communication
compromising patient safety. While this handbook recognises that the safest course for the
use of abbreviations, acronyms and local terms in healthcare is zero use it also recognises
that the complete absence of abbreviations, acronyms and local terms in health records may
never occur.
The electronic environment offers the potential to collect data using tools that provide clear,
full descriptions of information rather than the use of abbreviations, acronyms and local
terms and can ensure that, where abbreviations, acronyms and local terms are used, their
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full description is provided as a confirmation of data entry. Data presentation using
abbreviations, acronyms and local terms must be limited to ensure clarity and safety of
directions and usage. For example, frequently used abbreviations such as ‘bid’, also written
as ‘bd’, means twice a day in one context and ‘Bought in Dead’ in another. This may be
appropriate where the information does not need to be accessed, shared or communicated
with anyone else. Even in this circumstance the abbreviation needs to be accurately
interpretable over time and by others particularly in the medico -legal sense.
In recognition that people are unlikely to cease using short forms, this guideline has been
developed to minimise risk. It identifies principles, governance practices and the
relationships between these issues and terminologies in healthcare, with reference to
existing paper based systems, but largely focusing on the emergence of distributed health
care systems.
1.5 STAKEHOLDERS
The use and management of abbreviations, acronyms and local terms in healthcare is of
relevance to those using information to support safe, quality health care and to plan and
authenticate service delivery. This includes:
 Health consumers
 Individual and organisational providers of health services
 Professional associations providing advice to healthcare providers and
collectors of health information.
 Pharmaceutical industry and other suppliers to the health sector
 Service delivery planners and funders
 Researchers and publishers
 Health sector information and knowledge custodians
The introduction of clinical terminological systems in Australia will impact the need for
abbreviation management in the manual and the computerised environment; stakeholders
here will include
 Software developers and vendors
 Clinical terminology development and standards organisations
1.6 STRUCTURE OF THE GUIDE
The guide is structured into sections, each dealing with an aspect of abbreviations,
acronyms and local terms management in health care.
Section 2 provides an overview of abbreviations, acronyms and local terms and the different
types of abbreviations, acronyms and local terms and concepts used in health care.
Section 3 discusses the principles of good management required for abbreviations,
acronyms and local terms. The risks associated with the use of these types of terms are
identified and strategies that can help minimise these risks are explained.
Section 4 identifies the issues relevant to the management of abbreviations, acronyms and
local terms in relation to national terminological systems.
Section 5 contains a list of organisations from which help can be sought when managing
abbreviations, acronyms and local terms.
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OVER V IE W OF AB BR E V IAT IO NS ,
AC R ONYM S AND LOC A L TER M S
1.7 WHAT ARE ABBREVIATIONS, ACRONYMS AND LOCAL TERMS?
1.7.1 Abbreviations
An abbreviation is “a shortened or contracted form of a word or a phase used as a symbol
for the whole” (Macquarie Dictionary, 3 rd ed. 1997).
1.7.2 Acronyms
An acronym is a memorable combination of the first letters of the words of a name. While
abbreviations are useful in text where space is limited, acronyms are particularly convenient
for shortening verbal communication in addition to written materials. (ISO/TR 15031-2:
2004, p 4).
Acronyms tend to start out in life as capitals which then reduce to lower case as the words
formed become accepted as a lexical item and people cease to analyse it into its component
parts. However, if there is a possibility of confusion with some other homograph, this
process is arrested” (Macquarie Dictionary, 3rd ed, 1997)
A heteronymous acronym is an acronym that is identical to another, but the words
represented are different. For example the acronym a.c.a can mean adenocarcinom a,
anterior cerebral artery or anti cardiolipin antibody (source: The Drs Reference Site
http://www.drsref.com.au/cgi-bin/acronym.pl?start=0&perPage=10&search=aca)
1.7.3 Local Term
Synonym: colloquial term
A local term is the creation, modification or corruption of accepted language in a local
context. This is done for a number of reasons: convenience, parochialism, specificity, and
lack of knowledge of alternatives already accepted in the wider community.
1.8 WHY ARE THESE CONCEPTS USED SO FREQUENTLY IN HEALTH CARE?
Work practice – speed and ease of use.
In the English language, the widespread use of abbreviations, acronyms, and local terms has
been popular for many years. These have always been a part of the jargon of healthcare. The
purpose for using these is to simplify speaking, writing and ultimately communicating, without
losing meaning. Healthcare has always been peppered with long scientific, biomedical and
Latin terms making the oral pronunciation difficult and their recording slow and challenging.
As healthcare has evolved the language that underpins it has also evolved but at the same time
many of the Latin expressions and terms have remained and the use of abbreviations, acronyms
and local terms has become commonplace. This practice is increasing exponentially as the need
arises to reduce the time taken to record healthcare as workloads and the volume of information
increases. The use of shorthand notation such as abbreviations seems to be increasing as the
complexity of healthcare increases. This is reinforced in education where theory and
practice meet and domain knowledge jargon is perpetuated. A more recent push for
abbreviation is in the subset of acronyms and heteronymous acronyms. While it is not a
requirement that acronyms form words in their own right, this is often strived for, adding more
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confusion to the already confused world of abbreviations. Some acronyms are so mainstream
now that they have become ubiquitous and are used universally; for example, the use of FYI
(for your information) is well recognised and interpreted by most.
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M ANAGEM ENT
P R INC IP LES
1.9 INTRODUCTION
This section identifies the principles and methods appropriate for the management of the
use of abbreviations, acronyms and local terms in health information.
In response to a steady stream of reported errors caused by misinterpretation of dose
expressions, abbreviations, acronyms and local terms, many institutions involved with patient
safety have begun to recommend abandoning their use all together (Institute for Safe
Medication Practices (ISMP). While this handbook recognises that the safest course for the
use of abbreviations, acronyms and local terms in healthcare is zero use, it also recognises
that the complete absence of abbreviations, acronyms and local terms in health records is
unlikely to occur.
The dangers of using abbreviation are real and recognised as a safety issue for healthcare.
Abbreviations, acronyms and local terms are prone to misinterpretation, as demonstrated below.
1) The abbreviation for the drug DPT diphtheria-pertussis-tetanus being mistaken for
Demerol-Phenergan-Thorazine
2) CPX (cystic fibrosis) confused with CTX a chemotherapy drug (Cytoxan).
3) Heparin 800 units/hour was ordered, but the medical practitioner used the
abbreviation "u" for units. The "u" was misread as another zero (0) and the patient
received a ten-fold overdose (i.e., 8,000 units/hour) for approximately four hours.
4) A death was reported following the misinterpretation of frusomide 40 mg Q.D
(daily) as frusomide 40 mg QID (four times a day).
Other common examples:

µg (microgram)
Mistaken for
mg (milligram)

U (unit)
Mistaken for
0, 4, cc

IU (international unit) Mistaken for
IV or 10

.5 (0.5)
5

DC
curettage
Mistaken for
Used as discharge or discontinue or dilatation and
The enormity of the problem can be seen in web sites that have in excess of one hundred
thousand (100, 000) health abbreviations (for example, www.pharma-lexicon.com) and the
book ‘28,000 Conveniences at the Expense of Communications’ and Safety (Davis, 2006)
that lists 18,000 abbreviations, acronyms, and symbols and 28,000 of their possible
meanings
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1.10Identification of Context
The importance of knowing context within which the information was documented and the
contextual variables associated with that original information are essential for safe care
delivery. To clearly indicate context we must know:
 The designation of the person recording the information,
 The form used to record the information,
 The field on a form,
 The time and date at which it was recorded,
 The clinical specialty area,
 The location (e.g. hospital emergency department)
The identification of context is crucial in many cases as the following case study illustrates:
The patient was receiving sliding scale insulin. Her blood glucose was stable for a few
days, so the physician wrote an order to ‘Decrease Accuchecks to BID. If no Insulin
required x 48 h, d/c SSRI.’ By the context of the order, ‘SSRI’ was intended to mean
sliding scale regular insulin. Two days later, the patient had not required any insulin for
48 hours, so the nurse wrote an order as ‘SSRI to be discontinued (per MD order)’.
Patient has not required insulin over past 48 hours." This order was not sent to the
pharmacy, but was communicated to the pharmacist via a note as ‘d/c SSRI.’ The
pharmacist located the patient's profile, noticed the patient was receiving sertraline (a
selective serotonin reuptake inhibitor), and discontinued that (US Pharmacopeia 2006).
Insert table from HG document
1.11Reference List
1.12 Maintenance Processes
insert HG para here
Tools to facilitate manual documentation of activities associated with medication administration
are necessary for example an accurate, updated medication administration history, alongside
other patient data such as allergies and order information is essential.
1.13 Notification Processes
Processes appropriate to notify national bodies of the introduction or retirement of
abbreviations in active use.
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R E LAT ION S H IP TO N A T IONA L C LIN IC A L
TER M IN O LO GY GOVER N ANC E
1.14 WHERE DO ABBREVIATIONS, ACRONYMS AND LOCAL TERMS FIT
INTO A NATIONAL CLINICAL TERMINOLOGY?
Explain here the need to submit these to national governance processes and explain the
technical aspects of interface terminology and local term management. Particularly
consider the dangers of not sharing all the way through the system.
1.15 STANDARDISED IMPLEMENTATION IN SYSTEMS
Discussion of the ability of software vendors to use their own systems, and to link (map )
these to the national systems and the need to recognise the maintenance and safety issues
inherent in this process. Need to suggest best practice is to minimise local variety and to
have nationally provided sets that can be automatically ‘loaded’ into l ocal systems.
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C ONTAC TS
AC R ONYM S
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ON AB BR E V IAT IO NS ,
AND LOC A L TER M S
1.16 NATIONAL GOVERNANCE
Statement about SNOMED and the contact details for input or questions.
1.17 DOMAIN GUIDANCE
Advice on the relevant terms for specific health care domains should be sought from the
professional association.
1.18 GENERAL SYSTEM GUIDANCE
HIMAA?
NEHTA
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