Page 23 - Part One Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

course. You do not want to be explaining that in a deposition or in

front of a jury as it certainly will 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 July 2018, the Joint
Commission updated its FAQ regarding acceptable abbreviations.
2
It clarified that there is 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. However, if multiple
abbreviations, symbols, or acronyms exist for the same term,

2 https://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=1806&ProgramId=4
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