Abbreviations/Symbols in Medical Records

In response to concerns expressed by hospital representatives, the Missouri Department of Health and Senior Services issued a letter clarifying the use of abbreviations or symbols used in patients’ medical records.

Survey staff will be advised to interpret the current regulation, 19 CSR 30-20.021(3)(D)4 in the following manner. Text in italics indicates new language.

“Each abbreviation or symbol shall have only one (1) meaning, unless otherwise readily defined in the context of use, and an explanatory legend shall be available for use by all concerned. There shall be a list of abbreviations and symbols that shall not be used in handwritten communications.”

The letter also lists examples of acceptable compliance methods. This new interpretation will allow using an abbreviation specific to the unit or condition for which a patient is receiving care. As always, compliance with written policies and staff training are vital in ensuring that the use of multiple abbreviations is done safely and in keeping with the regulations.

DHSS_abbreviations.pdf