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THE UNIVERSITY OF CONNECTICUT HEALTH CENTER JOHN DEMPSEY HOSPITAL ADMINISTRATIVE MANUAL SECTION: RECORDS MANAGEMENT NUMBER: 12-002

SUBJECT: APPROVED AND NON-APPROVED ABBREVIATIONS AND CHARTING TERMS PURPOSE: To provide uniformity of charting terms and abbreviations for ease of interpretation. In order to reduce error and foster clarity of written communication, only approved abbreviations and symbols shall be used when making entries in the medical record. This policy will serve as a resource as to the abbreviations which have been approved for use, as well as those that are not acceptable for use in the medical record documentation at UCONN Health Center. The Health Information Management Committee provides final approval and oversight for all decisions that surround abbreviation usage. 1. Abbreviations are used to lighten the burden of record documentation, however, the use of abbreviations may be easily misinterpreted if the abbreviation is not written in context, or if the abbreviation is not understandable to others who utilize the documentation. The current edition of "Steadman's Medical Abbreviations, Acronyms and Symbols" has been selected as the approved, official abbreviation list and formal reference for approved abbreviations at UCONN Health Center. It is available under "LINKS" on the netaccess tool bar in LCR. The Health Information Management Department will maintain the upkeep of this publication. To utilize this reference to validate abbreviations approved for use, users may type in the intended abbreviation and press enter. The acceptable interpretation(s) will appear on the right (see below).

Type in abbreviation you would like to search and press enter.

Acceptable usage for this abbreviation will display.

2. Abbreviations that appear on the unacceptable list of abbreviations are also posted under "LINKS' on the netaccess tool bar in LCR. These abbreviations are NOT permitted under any circumstances (see below).

3. Clarification is required if staff is unclear about a written "Do Not Use" abbreviation. 4. If the intent of the abbreviation, acronym or symbol is susceptible to more than one interpretation consider the context in which the abbreviation is used. 5. If an abbreviation is not listed in the Steadman's abbreviation reference, the author of the entry is asked to write out the phrase instead of using an abbreviation that can be misunderstood.

6. Abbreviations are NOT to be used on consent forms or when listing the patient's final diagnosis, operative or procedural titles, and complications in discharge summaries or operative reports.

___________________________ Mike H. Summerer, MD Hospital Director Date Issued: Date Revised: Date Reviewed:

___________________________ Richard H. Simon, MD Chief of Staff

1/75 1/86, 11/88, 9/91, 11/91, 10/94, 7/03, 2/08, 6/09 10/97, 2/00, 7/01

~Attachments (Exhibit B "Unapproved Abbreviation List" can be found in the Hospital Administrative Manual~

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