Review /Development ofa Regional Abbreviation Policy

1st May 2013

Purpose

In response to the request from the ‘Recording Care’ Project in the review and development of

an agreed abbreviation policy

Definition:• An abbreviation (from Latin brevis, meaning short) is a shortened

form of a word or phrase. Usually, but not always, it consists of a letter or group of letters taken from the word or phrase. For example, (worryingly), the word abbreviation can itself be represented by the abbreviation abbr., abbrv. or abbrev.

• In strict analysis, abbreviations should not be confused with contractions or acronyms (including initialisms), with which they share some semantic and phonetic functions, though all three are connoted by the term "abbreviation" in loose parlance

• An abbreviation is a shortening by any method

Literature Review – some key messages• Care records are comprehensive, accurate, clear and free from

unauthorised abbreviation (Essence of Care, 2010)

• Jargon free, abbreviation free, (RCN, 2010)

• Avoid abbreviations (NMC, 2009)• Records should be factual and not include unnecessary

abbreviations, jargon, meaningless phrases or irrelevant speculation.

• The language that you use should be easily understood by the people in your care.

Lit Review

• To make the system effective, the list would have to be accompanied by a policy that using a abbreviation which is not on the list would be a disciplinary matter (Dimond 2005)

• It is recommended that each healthcare facility draw up an approved list of abbreviations. The list should be periodically reviewed and, if necessary, updated – (An Bord Altranais 2002)

Lit Review

• More than 80 percent of the respondents supported the creation and adoption of a “do not use” list. National Patient Safety Goal http://www.jointcommission.org/standards_information/npsgs.aspx

• Good practice to use plain English and avoidthe use of jargon or abbreviations whenever possible - Information Commissioner Officer (2012) http://www.ico.gov.uk

International

South West Australia (2009) Policy Directive• Legal requirements

Before using any form of abbreviation, nurses and midwives must ensure that the abbreviation is

approved in the individual clinical setting. If there is any doubt, nurses and midwives must

not use any abbreviations and write all words in full

International

Canada - Self assessment toolUsing abbreviations and symbols appropriately by

ensuring that each has a distinct interpretation and appears in a list with full explanations

approved by the organization or practice setting

Perspectives:

• Abbreviations: the need for legibility and accuracy in documentation. Br J Nurs. 2005 Jun 23-Jul 13;14(12):665-6.

• The use of abbreviations in medical records in a multidisciplinary world--an imminent disaster. Commun Med. 2008 ;5(1):25-33

• Abbreviations and acronyms in healthcare: when shorter isn't sweeter. Kuhn IF. Pediatr Nurs. 2007 Sep-Oct; 33(5):392-8.

Initiative - Aim

To regionally agree a way forward in the use of abbreviations by

nurses and midwives in the first instance with an aim to agree a regional policy for

acceptance and endorsement through the office of Chief Nursing Officer

Objectives

• To identify existing practice in relation to the use of abbreviations

• To develop high level principle statements in the use of abbreviations in record keeping practice

• To develop policy advice in attaining/ maintaining acceptable standards of use of abbreviations in practice

contd

• To identify and agree a standard, approved abbreviations list

• To incorporate the agreed list into the Regional

Health and Social Care Nursing Document • To review abbreviation approach in Maternal

Hand Held Record.

Record Keeping Audit

Initiative Plan

• Terms of Reference agreed

• Work-Plan drafted and agreed

• Membership – Expert Reference Group

established

Terms of Reference

• TOR 1 To agree the initiative plan and timescales for the project

• TOR 2 To contribute to the achievement of the initiative aims and objectives

• TOR 3 To undertake ongoing monitoring of the initiative against the planned activity

TOR contd

• TOR 4 To agree a mechanism of progress reports from the Project Lead to Recording Care Group

• TOR 5 To contribute to the agreed policy and report for submission to the DHSSPS

Note:• The Expert Reference Group will meet on approximately 3 occasions.• Membership of Expert Reference Group is non-transferrable except in

exceptional circumstances and with prior agreement of the Chair.