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Review /Development of a Regional Abbreviation Policy

Review /Development of a Regional Abbreviation Policy. 1 st May 2013. Purpose. In response to the request from the ‘Recording Care’ Project in the review and development of an agreed abbreviation policy. Definition:.

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Review /Development of a Regional Abbreviation Policy

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  1. Review /Development ofa Regional Abbreviation Policy 1st May 2013

  2. Purpose In response to the request from the ‘Recording Care’ Project in the review and development of an agreed abbreviation policy

  3. Definition: • An abbreviation (from Latin brevis, meaning short) is a shortened form of a word or phrase. Usually, but not always, it consists of a letter or group of letters taken from the word or phrase. For example, (worryingly), the word abbreviation can itself be represented by the abbreviation abbr., abbrv. or abbrev. • In strict analysis, abbreviations should not be confused with contractions or acronyms (including initialisms), with which they share some semantic and phonetic functions, though all three are connoted by the term "abbreviation" in loose parlance • An abbreviation is a shortening by any method

  4. Literature Review – some key messages • Care records are comprehensive, accurate, clear and free from unauthorised abbreviation (Essence of Care, 2010) • Jargon free, abbreviation free, (RCN, 2010) • Avoid abbreviations (NMC, 2009) • Records should be factual and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation. • The language that you use should be easily understood by the people in your care.

  5. Lit Review • To make the system effective, the list would have to be accompanied by a policy that using a abbreviation which is not on the list would be a disciplinary matter (Dimond 2005) • It is recommended that each healthcare facility draw up an approved list of abbreviations. The list should be periodically reviewed and, if necessary, updated – (An Bord Altranais 2002)

  6. Lit Review • More than 80 percent of the respondents supported the creation and adoption of a “do not use” list. National Patient Safety Goal http://www.jointcommission.org/standards_information/npsgs.aspx • Good practice to use plain English and avoidthe use of jargon or abbreviations whenever possible - Information Commissioner Officer (2012) http://www.ico.gov.uk

  7. International South West Australia (2009) Policy Directive • Legal requirements Before using any form of abbreviation, nurses and midwives must ensure that the abbreviation is approved in the individual clinical setting. If there is any doubt, nurses and midwives must not use any abbreviations and write all words in full

  8. International Canada - Self assessment tool Using abbreviations and symbols appropriately by ensuring that each has a distinct interpretation and appears in a list with full explanations approved by the organization or practice setting

  9. Perspectives: • Abbreviations: the need for legibility and accuracy in documentation. Br J Nurs. 2005 Jun 23-Jul 13;14(12):665-6. • The use of abbreviations in medical records in a multidisciplinary world--an imminent disaster. Commun Med. 2008 ;5(1):25-33 • Abbreviations and acronyms in healthcare: when shorter isn't sweeter. Kuhn IF. Pediatr Nurs. 2007 Sep-Oct; 33(5):392-8.

  10. Initiative - Aim To regionally agree a way forward in the use of abbreviations by nurses and midwives in the first instance with an aim to agree a regional policy for acceptance and endorsement through the office of Chief Nursing Officer

  11. Objectives • To identify existing practice in relation to the use of abbreviations • To develop high level principle statements in the use of abbreviations in record keeping practice • To develop policy advice in attaining/ maintaining acceptable standards of use of abbreviations in practice

  12. contd • To identify and agree a standard, approved abbreviations list • To incorporate the agreed list into the Regional Health and Social Care Nursing Document • To review abbreviation approach in Maternal Hand Held Record.

  13. Record Keeping Audit

  14. Initiative Plan • Terms of Reference agreed • Work-Plan drafted and agreed • Membership – Expert Reference Group established

  15. Terms of Reference • TOR 1 To agree the initiative plan and timescales for the project • TOR 2 To contribute to the achievement of the initiative aims and objectives • TOR 3 To undertake ongoing monitoring of the initiative against the planned activity

  16. TOR contd • TOR 4 To agree a mechanism of progress reports from the Project Lead to Recording Care Group • TOR 5 To contribute to the agreed policy and report for submission to the DHSSPS Note: • The Expert Reference Group will meet on approximately 3 occasions. • Membership of Expert Reference Group is non-transferrable except in exceptional circumstances and with prior agreement of the Chair.

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