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New JCAHO documentation guidelines required nationwide

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The Joint Commission on Accreditation of Hospitals and Healthcare Organizations (JCAHO) recently expanded its 2004 National Patient Safety Goals. These goals now include a list of “dangerous” abbreviations, acronyms, and symbols that you shouldn't use in clinical documentation. They apply to “all handwritten, patient-specific documentation,” but also should be applied to computer documentation as software programming is adjusted and as stocks of preprinted forms are used up. The guidelines cover all clinical documentation, including order forms and documentation, progress notes, consultation reports, and operative reports.

Starting January 1, 2004, all accredited facilities are required to include the following terms on their “Do not use” list. The guidelines specify not using them in any of their forms—upper or lower case; with or without periods.

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Besides the abbreviations listed above, different facilities may include others on its list, such as those shown below. As you travel to assignments in various locations, stay alert to this possibility. Make sure you get a copy of each facility's policies and procedures, then follow them to the letter.

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© 2004 Lippincott Williams & Wilkins, Inc.

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