HCM 205 Module 3 Abbreviations Short Paper Example

MS, RA and D/C: Auditing Abbreviations at Hillcrest Medical Group

[Student Name]

Southern New Hampshire University

HCM 205: Medical Terminology

Module Three Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

MS, RA and D/C: Auditing Abbreviations at Hillcrest Medical Group

Abbreviations save time for the person writing them and cost time, or worse, for the person reading them. At Hillcrest Medical Group, referral notes, scheduling comments and orders are full of shorthand. This paper explains the forms shorthand takes, describes abbreviations known to cause harm, reports an audit of Hillcrest's notes and proposes steps to reduce risk.

Abbreviations, Acronyms and Symbols

An abbreviation shortens a word or phrase, such as hx for history. An acronym is formed from initial letters and often pronounced as a word or letters, such as COPD for chronic obstructive pulmonary disease. Symbols, such as the arrow for increase or the degree sign, compress meaning further. Pitt and Hendrickson (2020) classified acronyms and abbreviations, which they called alphabet soup, as a distinct category of medical jargon, one that patients rarely understand and that professionals outside a specialty often misread.

Why Abbreviations Mislead

In their review of shorthand in clinical practice, Sinha et al. (2011) found that many abbreviations carry more than one meaning, that interpretation varies by specialty and that misreadings can delay care or cause errors. They recommended limiting abbreviations to approved lists and writing terms in full where confusion is possible.

Why Abbreviations Persist

If abbreviations cause so many problems, why do clinicians keep using them? Documentation takes a large share of clinicians' time, and shorthand feels like a way to save minutes across dozens of notes a day. Many abbreviations are learned in training and used without thinking. Specialties develop their own shorthand that works well inside the specialty but confuses outsiders. Electronic records have added copy-and-paste text and templates that carry abbreviations forward from note to note. Understanding these pressures matters, because a policy that ignores them will be seen as extra work and quietly ignored.

Medication Abbreviations

Medication orders carry the greatest risk. Shultz et al. (2011) studied non-intuitive medication abbreviations, such as those for drug names or dosing schedules, and found that pharmacy and nursing staff frequently misinterpreted them, creating potential for medication errors. Accrediting bodies and safety organizations maintain lists of notations that should never be used, including U for units, which can be mistaken for a zero; QD and QOD for daily and every other day, which are easily confused; a trailing zero after a decimal, which can turn 1 mg into 10 mg; and MS, which can mean morphine sulfate or magnesium sulfate.

The Hillcrest Audit

The writer reviewed 200 randomly selected referral notes, scheduling comments and orders from the past three months. The review found 412 abbreviations, of which 38 distinct abbreviations had more than one plausible meaning in context. Six notes used dose notations on the do-not-use list, all in medication refill requests routed through the front desk.

Ambiguous Abbreviations Found

The table lists the most common ambiguous abbreviations and the meanings each could carry at Hillcrest. Several map to different departments, which means a misreading sends a patient to the wrong clinic.

Table 1. Ambiguous Abbreviations in 200 Clinic Notes

Note. Composite audit of referral notes, scheduling comments and orders.

Effects on Administrative Work

Ambiguous abbreviations affect more than clinical care. A referral reading MS eval was scheduled with neurology when the referring cardiologist meant mitral stenosis. A note reading PT 2x/wk was booked as physical therapy when the physician wanted twice-weekly prothrombin time checks for a patient on warfarin. In billing, CA on an encounter form led a coder to query whether the diagnosis was cancer. Each required calls to clarify and delayed care.

Where the Risk Concentrates

The audit showed that ambiguity was not evenly spread. Referral notes from outside practices contained twice as many ambiguous abbreviations as internal notes, because referring clinicians use their own specialty's shorthand. Refill requests phoned in by patients and typed by front-desk staff produced most of the do-not-use dose notations. Scheduling comments written quickly between calls used informal shorthand, such as f/u for follow-up and appt for appointment, which rarely caused harm. Focusing safeguards on referrals and medication requests would address most of the risk with the least disruption.

Patients Read Notes Too

Patients now read many of their notes through online portals. Abbreviations such as SOB, which a patient may read as an insult, or c/o, complains of, which can sound dismissive, can damage trust. Writing terms in full serves patients as well as staff.

Proposed Clinic Policy

The writer recommends four steps. First, adopt an approved abbreviation list limited to unambiguous terms and publish the do-not-use list at every workstation. Second, configure the electronic record to expand approved abbreviations automatically and flag do-not-use notations in orders. Third, require that referral reasons and medication instructions routed through the front desk be written in full. Fourth, teach front-desk staff to read back and clarify any abbreviation that could have more than one meaning before scheduling.

Training for Front-Desk Staff

A thirty-minute session will cover the do-not-use list, the ten most ambiguous abbreviations found in the audit and a simple rule: when in doubt, ask. Staff will receive a pocket card and practice decoding sample notes. The audit will be repeated in six months to measure change.

Limitations

The audit sampled only notes that passed through the front desk and may understate ambiguity in clinical documentation. Judgments about whether an abbreviation was ambiguous depended on context and were made by one reviewer, though a nurse checked a sample.

Conclusion

Abbreviations are efficient for writers and risky for readers, especially readers outside the writer's specialty. Hillcrest's audit found dozens of ambiguous abbreviations that affected scheduling, billing and patient trust. An approved list, electronic safeguards, full-text rules for key fields and trained staff who ask before guessing can reduce those risks.

References

Pitt, M. B., & Hendrickson, M. A. (2020). Eradicating jargon-oblivion: A proposed classification system of medical jargon. Journal of General Internal Medicine, 35(6), 1861-1864. https://doi.org/10.1007/s11606-019-05526-1

Shultz, J., Strosher, L., Nathoo, S. N., & Manley, J. (2011). Avoiding potential medication errors associated with non-intuitive medication abbreviations. The Canadian Journal of Hospital Pharmacy, 64(4), 246-251. https://doi.org/10.4212/cjhp.v64i4.1036

Sinha, S., McDermott, F., Srinivas, G., & Houghton, P. W. J. (2011). Use of abbreviations by healthcare professionals: What is the way forward? Postgraduate Medical Journal, 87(1029), 450-452. https://doi.org/10.1136/pgmj.2010.097394