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Abbreviations are used to save time and space while writing notes but they should be used sparingly. Extensive use of abbreviations is a major cause of confusion and poor communication in patient care. Using unclear abbreviations can threaten patient safety. For this reason The Joint Commission keeps a “Do Not Use” list of abbreviations.1 Using too many or incorrect abbreviations can also cause denial of payment if the reviewer at the reimbursement agency cannot understand what happened in physical or occupational therapy. A list of commonly used abbreviations should be attached to any documentation requested by third-party payors.
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To ensure that everyone involved in the patient's care can understand what others have written in the health record, most healthcare facilities have a list of approved abbreviations, and if they do, those are the only abbreviations that should be used in that particular facility.2 A committee at each facility approves this list. The list of acceptable abbreviations varies from one facility to the next and includes abbreviations used by many health professionals. This list should include the abbreviations used in physical and occupational therapy.
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The list of abbreviations that follows will be used as the approved list for all of the worksheets in this book. Any abbreviations not on this list are considered unacceptable to use in these worksheets. When on your clinical rotations and when you begin your career, remember to use the list of acceptable abbreviations for your clinical facility. During orientation to any clinical facility in which you practice, ask about the location of the approved abbreviations list and familiarize yourself with those abbreviations the facility uses frequently.
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Approved Abbreviations and Symbols for Healthcare Facility XYZ
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