/policies/,/policies/administrative/,/policies/administrative/uw-health-administrative/,/policies/administrative/uw-health-administrative/health-information-management/,

/policies/administrative/uw-health-administrative/health-information-management/618.policy

20160232

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UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Health Information Management

UW Health Approved Abbreviation List (6.18)

UW Health Approved Abbreviation List (6.18) - Policies, Administrative, UW Health Administrative, Health Information Management

6.18


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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of UWHC
and UWMF.
Policy Title: UW Health Approved Abbreviation List
Policy Number: 6.18
Effective Date: January 1, 2016
Chapter: Medical Records
Version: Revision
I. PURPOSE

To provide continuity and standardization in the use of medical abbreviations used by UW Hospitals and
Clinics Authority (UW Health) staff.

II. POLICY

Symbols and abbreviations used in the medical record should be kept to a minimum in order to avoid
misinterpretation and prevent patient injury. An approved abbreviation list will be maintained in keeping
with The Joint Commission (TJC) and Wisconsin Administrative Code, DHS 124.14(5)(b). Abbreviations
in the "DO NOT USE" list shall not be used in UW Health medical records, except as expressly permitted
in the procedures below.

III. PROCEDURE
A. Only abbreviations on the UW Health approved abbreviation list may be used when documenting
in the UW Health medical record (paper and electronic).
B. For abbreviations not on the UW Health approved abbreviations list (investigational drug
protocols, newer diagnostic techniques, etc.) the term must be spelled out the first time it is used
in each document or form or a Key detailing the spelled out term and its abbreviation may also be
placed on the document or near the section in which the abbreviation is used in the electronic
medical record. The Neal M. Davis Medical Abbreviations resource is the approved abbreviation
list for UW Health. The Director, Health Information Management, or his/her designee, approves
any additional abbreviations or deletions to a separately maintained UW Health-specific approved
abbreviation list (those not included on the Neal M. Davis resource). Requests for additions or
deletions should be submitted to the Director or designee. Decisions by the Director, or
designee, may be appealed to the Medical Record Committee which may make additions or
deletions from the list. Generally, abbreviations not in the book Medical Abbreviations, by Neil
M. Davis, will be approved upon request, but may not be used until added to the UW Health
supplemental approved abbreviations list.
C. The hyperlink to the Neal M. Davis Medical Abbreviations resource and the UW Health-
approved Supplemental Abbreviation List can be accessed on the page of U-Connect where this
Policy appears, under the Related Tab.


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D. Abbreviations may not be used when recording final diagnoses.
E. Abbreviations should not be used in titles of documents (see Health Link Content Management
and Style Guide).
F. Abbreviations with more than one definition should be interpreted within the context of the
documentation.
G. Unacceptable abbreviations, listed below, cannot be used for documenting in the UW Health
medical record.
"DO NOT USE" ABBREVIATION LIST
iu qd
qod u (instead use "unit")
MS or MSO4 MgSO4
lack of a leading zero use of a trailing zero

*Note that abbreviations on the "DO NOT USE" list should not be used in any form - upper or
lower case; with or without periods.
H. Trailing zeros are permitted in printed or electronic laboratory reports, but not handwritten
laboratory reports.
I. The error-prone abbreviations, cc, ug and tiw, are not on the "Do Not Use" Abbreviation list,
however, their use is strongly discouraged.
J. Orders shall be verified with the ordering prescriber when an error-prone abbreviation is used
(please see Administrative Policy 8.16-Patient Care Orders).
K. Laboratory tests may be abbreviated in accordance with the Lab Test Directory. The Laboratory
will provide Health Information Management with a current version whenever the Lab Test
Directory is updated.
IV. REFERENCE
Medical Abbreviations by Neil M. Davis
V. COORDINATION

Sr. Management Sponsor: SVP, Chief Information Officer
Author: Director, Health Information Management

Approval Committee (s): Medical Record Committee; UW Health Administrative Policy & Procedure
Committee; Medical Board

SIGNED BY

Ronald Sliwinski
President, University of Wisconsin Hospitals
Chief of Clinical Operations

Revision Detail:

Previous revision: 112013
Next revision: 012019