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Should written policies be developed for abbreviation usage

Customer Question

Should written policies be developed for abbreviation usage? If yes, what should the policies contain?
Submitted: 5 years ago.
Category: Computer
Expert:  Jerry Hannell replied 5 years ago.
In many medical situations time is of the essense. Either because of medical urgency or medical practice needs (such as insurance company time management issues) there are many times when a doctor, particularly in his/her private practice does not have the time to write out every single word in a patient's file or report. However, only if the medical profession as a whole, through the AMA, ADA, state nursing associations, state medical boards, etc. all create a standardized set of abbreviations, similar to what the legal profession has done with Latin terms or the Black's Law Dictionary, will the use of abbreviations be allowed.

These "policies" should not be policies, but standards - broadly used in the medial field. They must strictly define an abbreviation to mean a single thing and then create a reference book, such as that available for prescription medicines, for use by medical professionals and their staff. The industry, as a whole, must emphasize that deviations from this reference set are not permitted due to the danger involved.

The Medicare service, under HIPAA has recognized the need for uniformity to allow proper communication and payment for treatment. Under HIPAA Medicare has specifically required medical providers to follow a list of treatment and other codes (see http://www.cms.hhs.gov/TransactionCodeSetsStands/). This list of codes was designed to permit accurate transmission of information. Accuracy, particularly where a person's health could easily be compromised due to inaccurate interpretations of self-defined abbreviations, which others who do not know the writer, may not understand.


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I hope that helps sir,
Jerry H.

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