Page 24 - Risk Reduction Series - Documentation Essentials (Part One)

SVMIC Risk Reduction Series: Documentation Essentials

not come across as funny. Again, use objective terms and the

patient’s own words to describe those impressions. It will likely
create an even more accurate picture.

Of course, there is a place for acceptable acronyms,

abbreviations, macros, and other documentation shortcuts.
Generally, the facility and other entities will identify the

acceptable terms as well as other specific documentation
guidelines. In June 2020, the Joint Commission updated its FAQ

regarding acceptable abbreviations. It clarified that there is
2
not a required list of acceptable abbreviations. However, Joint

Commission requires that organizations use ‘standardized’
abbreviations. Any reasonable approach to standardizing

abbreviations, acronyms, and symbols is acceptable. Examples
may include:

• Standardized abbreviations developed by the individual
organization.

• Use of a published reference source. However, if multiple
abbreviations, symbols, or acronyms are used for the

same term, the organization identifies what will be used to
eliminate any ambiguity.

• A decision that individuals who work in the organization
may use any abbreviation, acronym, or symbol that is not

on the list of unacceptable abbreviations.

The following list of abbreviations prohibited by The Joint
Commission is published in the Information Management (IM)

chapter of the accreditation manual at IM.02.02.01 and states

2 https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/
information-management-im/000001457/

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