Abbreviations & Number Safety in Documentation
Standardized terminology reduces misreading. Organizations decide which abbreviations are approved; follow your facility's policy.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyNo universal "approved" list
The Joint Commission does not publish a list of approved abbreviations. Each organization sets its own approved terminology, which differs between facilities. What The Joint Commission does publish is a minimum Do Not Use list for medication-related documentation, summarized below.
The Joint Commission minimum Do Not Use list
| Do not use | Potential problem | Use instead |
|---|---|---|
| U, u (unit) | Mistaken for 0 (zero), 4 or cc | Write "unit" |
| IU (International Unit) | Mistaken for IV or 10 | Write "International Unit" |
| Q.D., QD, q.d., qd (daily) | Mistaken for each other or for Q.I.D. | Write "daily" |
| Q.O.D., QOD, q.o.d., qod (every other day) | Period after Q mistaken for I; O mistaken for I | Write "every other day" |
| Trailing zero (X.0 mg) | Decimal point missed; 5.0 mg read as 50 mg | Write X mg (5 mg) |
| Lack of leading zero (.X mg) | Decimal point missed; .5 mg read as 5 mg | Write 0.X mg (0.5 mg) |
| MS | Can mean morphine sulfate or magnesium sulfate | Write "morphine sulfate" or "magnesium sulfate" |
| MSO4 and MgSO4 | Confused for one another | Write "morphine sulfate" or "magnesium sulfate" |
Summarized in original wording from The Joint Commission's Do Not Use list. The list notes that a trailing zero may be used where required to show the precision of a reported value (such as a lab result or tube size), but not in medication orders or other medication-related documentation. Check the source for current wording.
Leading and trailing zeros
Write 0.5 mg, not .5 mg. Write 5 mg, not 5.0 mg. These are the same number-writing rules used across the Dosage Calcs medication math lessons.
Other error-prone abbreviations
ISMP maintains a longer list of error-prone abbreviations, symbols and dose designations. Many organizations add items from it to their own policies.
Sources
- Do Not Use List (Facts about) — The Joint Commission
- Standards FAQ — abbreviations and dose designations — The Joint Commission
- List of Error-Prone Abbreviations, Symbols, and Dose Designations — Institute for Safe Medication Practices (ISMP)