Create a key to abbreviations

Decrease time spent on paperwork

Using abbreviations in patient treatment records increases efficiency by helping to keep the time spent on paperwork to a minimum. However, patient treatment records are also legal documents, and notations and their meanings should be the same in each record. Creating a "legend" or "key" to the abbreviations used in your office, and posting the legend where all employees can see it, will help to ensure that everyone uses the same abbreviations and that your records contain consistent and accurate information.

Some items to include when creating a key:

• the initials that are used to represent staff members and their full names
  
• universally recognized abbreviations, such as "WNL" (within normal limits)
  
• abbreviations that are not so familiar, such as "NPN" (no pathology noted) or "CEN" (clinical exam normal) and others that may be unique to your office
  
• precise definitions of abbreviations, such as "1 Xylo" which, depending on the concentration of vasoconstrictor used, could have several variations.