Coding, Classification & Reimbursement

The use of abbreviations within the medical record

  • 1.  The use of abbreviations within the medical record

    Posted 24 days ago
    ​As a CDI I have always asked a physician to write out the medical condition at least once in the record with the abbreviation linking  that term with the condition.

    We follow the Joint Commission Do No Use abbreviations.

    Is this just an "English 101" idea - or is there some direction from coding/CMS or another entity that requires this for accurate coding?

    Thank you in advance for your comments.

    Terry

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    Therese Peyton
    RN CCDS
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  • 2.  RE: The use of abbreviations within the medical record

    Posted 24 days ago
    Personally I try to be the example by using as few abbreviations as possible. Hospitals don't seem to keep up the approved list anymore. They all have the do not use list because of CMS and TJC. Both of which use enough abbreviations!  Since most everything is dictated, why use abbreviations? Is it saving the computer keystrokes?  For accuracy use words. Also- if I can't read it, I will ask for clarification. No slack for bad handwriting. It's just being obstinate in this day and age.

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    Nancy Coney BSN,RHIA, CCDS
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  • 3.  RE: The use of abbreviations within the medical record

    Posted 24 days ago
    I don't know about "official" guidelines for this, but as a coder I can tell you it definitely impacts the accuracy of coding.  Take, for instance, atrial fibrillation.  I see our doctors use the abbrevation "PAF" all the time.  Does this mean permanent afib, persistent afib, or paroxysmal afib? If they don't spell it out at least once there is no way to know which one they mean without querying them.

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    Carol Lamoureux
    Coding Specialist
    University of Minnesota Physicians
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  • 4.  RE: The use of abbreviations within the medical record

    Posted 23 days ago
    Thank you for these comments - they are helpful in explaining the potential confusion and inaccuracy they can cause.


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    Therese Peyton
    RN CCDS
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  • 5.  RE: The use of abbreviations within the medical record

    Posted 23 days ago
    Can we please be more accurate in our own communications, without typographical errors?

    On Wednesday, September 26, 2018, 8:14:51 PM CDT, Therese Peyton via American Health Information Management Association <Mail@ConnectedCommunity.org> wrote:


    Thank you for these comments - they are helpful in explaining the potential confusion and inaccuracy they can cause. ---------------------------... -posted to the "Coding, Classification & Reimbursement" community

    Coding, Classification and Reimbursement

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    Re: The use of abbreviations within the medical record
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    Therese M Peyton
    Sep 26, 2018 9:15 PM
    Therese M Peyton
    Thank you for these comments - they are helpful in explaining the potential confusion and inaccuracy they can cause.


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    Therese Peyton
    RN CCDS
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    Original Message------

    Thank you for these comments - they are helpful in explaining the potential confusion and inaccuracy they can cause.


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    Therese Peyton
    RN CCDS
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  • 6.  RE: The use of abbreviations within the medical record

    Posted 23 days ago
    I wish no offense to any one; I just seek accuracy, please.


    On Thursday, September 27, 2018, 10:32:48 AM CDT, Holly <bike4earth@yahoo.com> wrote:


    Can we please be more accurate in our own communications, without typographical errors?

    On Wednesday, September 26, 2018, 8:14:51 PM CDT, Therese Peyton via American Health Information Management Association <Mail@ConnectedCommunity.org> wrote:


    Thank you for these comments - they are helpful in explaining the potential confusion and inaccuracy they can cause. ---------------------------... -posted to the "Coding, Classification & Reimbursement" community

    Coding, Classification and Reimbursement

      Post New Message
    Re: The use of abbreviations within the medical record
    Reply to Group Reply to Sender
    Therese M Peyton
    Sep 26, 2018 9:15 PM
    Therese M Peyton
    Thank you for these comments - they are helpful in explaining the potential confusion and inaccuracy they can cause.


    ------------------------------
    Therese Peyton
    RN CCDS
    ------------------------------
      Reply to Group Online   View Thread   Recommend   Forward   Flag as Inappropriate  
    -------------------------------------------
    Original Message:
    Sent: 09-25-2018 17:58



     
    You are subscribed to "Coding, Classification and Reimbursement" as bike4earth@yahoo.com. To change your subscriptions, go to My Subscriptions. To unsubscribe from this community discussion, go to Unsubscribe. If you see any inappropriate posts, please go to the message and click the Mark as Inappropriate link.