abbreviations

katysuegood@gmail.com

when I first started this job a few months ago, i was told at one point that we had a list of approved abbreviations for the hospital. However, I recently looked for it and the previous policy which listed approved abbreviations has be replaced with a policy that only includes a short is of "do not use" abbreviations (about 10 total) and otherwise only has some basic suggestions on abbreviations.
The reason this came up is that I was doing some retrospective chart reviews in collaboration with coding and our coding manager (who is great) said that she would not pick up V-fib when documented as VF. This led to a discussion about approved abbreviations....
I am curious what other hospitals do in regards to abbreviations and what later happens when charts are coded. As CDS' do you attempt to clarify abbvreviations? Do the coders?

Thanks for your help,
Katy Good

Unknown

I clarify all abbreviations that are not included in the 'approved abbreviation' list.
When AKI first came out, I was querying left and right.

Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center

katysuegood@gmail.com

Our coders are coding dx like "ABL anemia" and other less common abbreviations. I dont know if this is good practice though and my larger concern is vulnerability to review. Even though the coder may ick up an abbrevaited dx, my assumption would be that if reviewed by an outsice company (RAC), this Dx would not stand up to review.
Correct?

The reason this issue came up early when I first started this job was related to ABL anemia. I was advocating adding it to our approved abbreviation list (which I guess we dont have anyways!) and was basically told by our physician liason that since he couldnt think of anything else that "ABL anemia" could mean, he thought it was fine for Drs to use it and coders to code it.

catladyrn

I had a physician write "SHF," meaning systolic heart failure, and I asked our CQAs (2nd level reviewers) if they would accept it without query. One said yes and the other said no. That's the kind of ambiguity that makes my job interesting, but not in a good way.

Renee


Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center

tiffany_susan

I have an abbreviation for you: AROBF......

awaiting return of bowel function, anyone heard this one before?

Thank You,
Susan Tiffany RN, CCDS
Supervisor Clinical Documentation Program
Guthrie Healthcare System

"Twenty years from now you will be more disappointed by the things you
didn't do than by the ones you did do. So throw off the bowlines. Sail
away from safe harbor.Catch the trade winds in your sails. Explore. Dream.
Discover." Mark Twain

robert.hodges2

And this is why our facility has an approved abbreviation list that is
used with a policy to back it up. Just to avoid this kind of confusion.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov



"We are dealing with Veterans, not procedures; With their problems, not
ours." --General Omar Bradley

tpeyton

Boy thats a new one on me....don't let my docs see that....LOL

Tracy M Peyton RN, CCDS
Case Management
Bradford Regional Medical Center
Upper Allegany Health Systems
116 Interstate Parkway
Bradford, PA 16701
814-558-0406

leah.taylor

That's not an approved abbreviation at our facility and no never seen it documented.

Leah Taylor,RN, CCDS
Iredell Memorial Hospital
557 Brookdale Drive
Statesville, NC 28625
E- leah.taylor@iredellmemorial.org
p- 704-878-7436
c- 704-402-9656