Although abbreviations are an extremely common thing which are used every single day throughout the medical field, it does not mean that they are always a helpful thing. Health care professionals generally use abbreviations during their work days to try to help them do things a bit more quickly so that they are able to move on to the next patient faster. One of the most common problems with using abbreviations is that it can sometimes be very difficult to decipher another person's handwriting. When a doctor or other medical personnel reads a patient's chart they may or may not always be able to understand exactly what another person has tried to abbreviate, either because of their handwriting or they may have accidentally written the abbreviation down wrong. In other cases the abbreviation may have been confused with another similar abbreviation, and that may end up causing a great deal of problems, not only for the patient but for whoever is in charge of dealing with the patient as well. There are quite a few things that can be done to help reduce the errors that abbreviations can cause such as; completely eliminating medical abbreviations, having written policies for the usage of abbreviations, knowing who should use them and when it would be acceptable, and why someone should use them in the medical field.
When it comes to eliminating the abbreviations in the medical field, this could greatly reduce some of the errors that occur on patient charts and in other types of important paperwork as well. Many of the medical abbreviations are quite similar and can cause a bit of confusion among some of the personnel. A great deal of errors involving abbreviations can occur when medical staff are trying to rush while they are writing d...
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...eat thing when they are used properly, but it is very important that the person using them knows when they should and should not be used. There are things that can be done to try reducing risks that are associated with the misuse of abbreviations. Although Eliminating all medical abbreviations would definitely help get rid of all the problems that follow, it does not have to be the only choice in the matter of reducing the risks. Making sure that all health care personnel follow the written policies that are in place is a very important part of working in the medical field. Accreditation agencies are now starting to compose lists of all the abbreviated terms that should not be used any more. Finally, abbreviations are an important part of any medical professional's life, but when it comes to handwritten documents it is often more of a nuisance rather then a blessing.
During the 1980’s and 90’s there were many studies done that showed that medical errors were occurring in inpatient and outpatient settings at a very high rate. Computer Provider Order Entry (CPOE) systems were designed to reduce or eliminate mistakes made by using hand written orders. The CPOE system allows users to directly enter their orders into the system on computers which are then sent directly to the healthcare providers that will be implementing the orders. Previously orders were placed by writing on order sheets on patient charts. This was sometimes done by the doctor or by a nurse acting on behalf of the doctor. Order sheets were then signed by the doctor and then the information was input into the patient’s record. This left room for error due to misreading bad handwriting, confusing medications with similar names, etc.
...ting legibly is the biggest concern. Having legible writing makes the whole operation of the radiology unit flow together. If the writing isn’t legible then it could cause the whole process to stop. Having the process stop isn’t good. It causes the process to be slower and risking peoples lives. For example, the x-rays can show blood flow. Having a very quick process could save someone’s life if they were bleeding out and needed a fast x-ray of where the bleeding was coming from and how it could be stopped. Having the writing be very clear and legible lives can be saved and make he process easy for the technician, radiologist, and physician.
Using standardized terminologies in nursing practice has a wide array of advantages to the patients, the organization involved, the nursing profession and even the country using the standards. These terminologies aid the healthcare organization (both the care team and administrators) in deciding which nursing terminology or a combination of several that suits their needs. With these terminologies:
Despite of errors that can be potentially generated by using abbreviations , the use of such shortened form of inscribing some words and medical orders has been a part of the practice and has not been eradicated. It would be therefore for the best and benefit of everyone to be well guided by written policies on usage of abbreviations. Standard policies on abbreviation usage have been developed by organizations such as The Joint Commission (ISMP, 2007). The JCAHO has been also striving to reach out to the healthcare professionals and organizations to help in elimination of errors rooting from the use of abbreviations (AARC, 2005). Org...
As a new user of reddit, one will notice there are many abbreviations and acronyms that a new user may not be aware of prior to visiting the site. Sub-reddit’s such as IAMA stand for “I am a” and feature popular users and celebrities such as Arnold Schwarzenegger, Bill Gates, and Barack Obama. There is a common form of communic...
Poor order transcriptions and documentation of orders given by doctors to nurses whether it’s verbal, written or over
Medicalization can either be a positive or a negative thing in society often some suffering from an illness turn to the label of medicalization to be able to be accepted from society. Medicalization can be positive for a society if it’s done for all the right reasons rather than just personal interest for those behind it.
On a daily basis, I will have to engage in charting and documentation writing to ensure patients receive the best possible care. Charting will involve patient identification, legal forms, observation, and progress notes. Documentation must be factual with objective information about the patients’ behaviors. Accuracy and conciseness are crucial characteristics of documentation in the nursing profession so that other medical professionals can quickly read over the information (Sacramento State,
When a doctor writes a prescription, he or she could not but a zero in front of the ones place. If the doctor does not put it in the ones place then it will look like the number is all ones and not in tenths , hundredths , thousandths , and ten – thousandths . It will look like the number is in ones, tenths , hundredths , thousandths , ten – thousandths . I think to make sure that no other errors in the mistaking a decimal point in prescriptions can no longer occur there should be some rules for the doctor. The doctor writing the prescription, if the prescription has a decimal in it , the doctor should put a zero in front of the decimal point to insure that there is no errors.There are many types of word phrases that will aid you in remember to help in math. My favorite is King Henry Died By Drinking Chocolate Milk. It’s a memorization trick used when you’re converting numbers with metric system endings. The K stands for Kilogram, H stands for Hectograms , D stands for Dekagrams , B is the base unit , D stands for decigrams , C stands for centigrams , and M stands for milligrams. The grams at the end of each word can be changed to different endings. The ending are meter, liter, and gram. When you have a number with a decimal number you either move left or right. When you move right or left you move the decimal to witch metric conversion you
this will cause healthcare providers with the training and education needed for clinical documentation improvements to be installed effectively. It is important that having a specialized team who can create solutions towards Clinical Documentation Improvement (CDI) in order to minimize the failures that may occur. In this case, investing in training for the materials/tools necessary for healthcare providers to excel in their work with CDI. Essentially, Clinical Documentation is used throughout the healthcare system for the analysis of care, communication, and medical records. This is important because the information of medical records that healthcare providers are able to access, will help patients track their health conditions. Thus, clinical documentation improvement has a direct impact on patients by providing quality information. On the other hand, the new technological advancements will also be able to address the efficiencies in health care system that differ from paper-based charting. Improving on the quality of information will also have the effect upon the ethical and effectiveness of care that is being provided. This has a significant impact in order to maintain patient care that ensures the documentation is accurate, timely, and reflect within the services provided. Documentation assessments can be utilized so there can be improvements on the education for healthcare providers as they intend implementation standards take effect immediately. In this case, failures must be analyzed so that they will have the ability to comprehend and determine an organization’s strengths and weaknesses
That is why complete, clear, concise notes are crucial, because they determine the type of code or level of complexity the services rendered are deemed justifiable. The diagnoses codes explain “why” the healthcare practitioner treated the patient during the encounter, procedural codes explain “what” the healthcare practitioner did exactly for the patient during their visit and E/M codes are used to determine the amount of compensation due to the provider for meeting with the patient face-to-face and his/her family members. For example; the diagnosis code for Deloris would be: Z00.00xx, CPT code(s) 2010F and 99385 and E/M code would be : 99201. These codes were based on the patient’s medical record for the services rendered during the office
Medical errors can happen in the healthcare system such as hospitals, outpatient clinics, operating rooms, doctor’s offices, pharmacies, patients’ homes and anywhere in the healthcare system where patients are being treated. These errors consist of diagnostic, treatment, medicine, surgical, equipment calibration, and lab report error. Furthermore, communication problems between doctors and patients, miscommunication among healthcare staff and complex health care systems are playing important role in medical errors. We need to look for a solution which starts changes from physicians, nurses, pharmacists, patients, hospitals, and government agencies. In this paper I will discuss how does the problem of medical errors affect our healthcare delivery system? Also how can these medical errors be prevented and reduced?
LaFleur Brooks, M. (2010). Exploring Medical Language, A Student – Directed Approach, 7th Edition, St. Louis: Mosby Elsevier.
It is surprising to know that many of the terms created in early times by the Greeks are still in use today. Medical terminology is a known language that has been used for a long period of time. Similarly to English, medical terminology is also universal to the healthcare or medical industry. It’s a language that helps people in the medical field understand completely what is happening or what has to be done in order to help a patient. This vast language is not just restricted to doctors, medical practitioners, and nurses as it is important for other workers in the healthcare industry as well.
It is essential to have impeccable typing skills, as accuracy is key to even the easiest transcription assignments – the simplest of errors can change the meaning of a word, phrase, or sentence and alter the originally intended interpretation of the audio report. Numbers and abbreviations, in particular, must be precise and written in their correct form because of the diversity of connotations they can potentially hold based on how the dictation is written. The utilization of punctuation, capitalization, or other keyboard symbols can make the difference between a correct and incorrect analysis. Occasionally, a number will need to be spelled out instead of typed as a figure for one reason or another. This means that, along with the other factors, the form of how a number is typed must be considered as well.