JCAHO’s abbreviation requirements adjusted
The Joint Commission on Accreditation of Healthcare Organizations has issued its final modifications to the National Patient Safety Goal 2b, which address its 2005 requirements for standardizing medical abbreviations and symbols.
The requirements now apply to pre-printed forms as well as handwritten documentation, but apply only to orders and medication-related documents.
The "prohibited abbreviations" requirement under the communication goal (2b) has changed in the following ways:
- It now applies to ALL orders and ALL medication-related documentation that are handwritten, utilize free text entry, or employ pre-printed forms.
- The minimum expected level of compliance for handwritten documentation and free text entry is 90%.
- The minimum expected level of compliance for pre-printed forms is 100%.
- Clarification of an order prior to implementation is expected but does not eliminate that occurrence from being counted. Similarly, after-the-fact correction of the order by the clinician does not eliminate that occurrence from being counted.
- Surveyors will count occurrences of "do-not-use abbreviations."
- One occurrence equals one or more "slips" per clinician per record.
- Three occurrences equal a Requirement for Improvement (Revised 1/21/05).
- There is no "partial compliance" for National Patient Safety Goals.
- This requirement will not be surveyed in electronic documentation or computerized order entry in 2005 (New 12/20/04).
"Monitoring of implementation by ED management is important to ensure effective implementation," says Darlene A. Christiansen, director of standards interpretation in the Joint Commission’s Office of Quality Monitoring.
"[Unless otherwise specified,] surveyors will look for 100% compliance," she notes.
Source
For information about the abbreviation requirements, contact:
- Darlene Christiansen, Director, Standards Interpretation/Office of Quality Monitoring, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5273. E-mail: [email protected].
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