Q&A: Is there an approved list of abbreviations for Ascension Wisconsin?

 

Question: Is there an approved list of abbreviations for charting at Ascension Wisconsin?

Answer: After checking with Medical Records, Informatics, Clinical Educators, Quality and others in-the-know, we determined that there is currently NO statewide list of approved abbreviations for Ascension Wisconsin for documenting care in the EHRs.   

But there is a team currently working on standardizing a policy statewide.

Some sites / regions may have their own approved abbreviations lists / policies (like the ones below), but there is nothing standardized statewide:

• Use of Abbreviations and Symbols (PolicyStat 10494144)  but it appears to be limited to The Fox Valley.
• Abbreviations Policy (PolicyStat 9522008) - Franklin - Elmbrook - St Joseph's Campus

For reference and patient safety, there are several DO NOT USE abbreviation lists:

• The Joint Commission's Official "DO NOT USE" List.
• The official DO NOT USE LIST from The Joint Commission (1-page pdf) (c2018)
• Facts about the Official "Do Not Use" List.
• TJC FAQ:  What are the key concepts organizations need to understand regarding the use of terminology, definitions, abbreviations, acronyms, symbols and dose designations?  (c2021)

• The Institute for Safe Medication Practices (ISMP) also keeps a list of error-prone abbreviations, symbols, and dose designations.

For a complete listing of what's possible, see
Dorland's Dictionary of Medical Acronyms (c2016) via Clinical Key, through Ascension Wisconsin Library Services.