Inside Angle
From 3M Health Information Systems
Abbreviations…The coder’s telephone game
We live in a communication age that embraces abbreviations and acronyms as a natural secondary language. Our emotions and reactions are reflected in “LOLs” and emojis on a regular basis. I openly admit there have been many times when a quick abbreviated email has made me turn to Google to understand what in the world the sender intended.
In the medical community, the use of abbreviations and interpretation of them is nothing new. It sometimes feels like the rest of the world is just catching up to us and learning how to deal with a reliance on acronyms and the challenges that come with it. I can recall multiple times when a series of letters in a note left a group of coders each with a different explanation of the abbreviation. In the end, the coders had their own interpretations based on the individual coder’s experience with the provider, how they had seen the code used in the past and the context of the abbreviation in the note.
We know that for the sake of time and efficiency, abbreviations and acronyms are a necessity in provider documentation, but improved time and efficiency must be balanced with documentation accuracy. An initial glance at “CP” could lead a coder to immediately correlate it with chest pain…but it could also be cerebral palsy. “MS” can represent multiple sclerosis, but a simple context change may have it represent morphine sulfate or magnesium sulfate. Did the provider’s use of “I” imply infection or illness? The documentation doesn’t change, but different interpretations carry specific outcomes, which impacts the encounter’s storyline and ultimately affects the accuracy of the code assignment and record of the patient’s diagnosis and treatment.
Abbreviations aren’t going anywhere anytime soon, so here are some things to keep in mind:
- When reading a note, avoid assuming the meaning of the abbreviation and stay objective.
- If an outside source or auditor was reading the note, would they interpret the abbreviation within the documentation the same way you have? You may know what your provider means, but will the auditor?
- Be sure to establish defined sections of your note. The reality is that context does play a big role in abbreviation interpretation, so clearly identifying documentation as part of a specific section can assist in clarification. Take the abbreviation “CAD,” for example. In the technique section, CAD can refer to a computer-aided detection but in the impression section, CAD may be referring to coronary artery disease.
- Be aware of the use of provider initials and titles. These should be documented in a clearly identified signature section at the bottom of the note.
We may not always know what to do with a friend’s “BRB” or “ROFL” (when all else fails, respond with a
7 thoughts on “Abbreviations…The coder’s telephone game”
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Allison Morgan, MS, CPC
Clinical Development Analyst
Allison Morgan, MS, CPC, CPCO, CPMA, is currently a Clinical Development Analyst with the HIS division at 3M. Her diverse background includes formal certification in coding and auditing, along with…
I think my least favorite — and most ambiguous — abbreviation I see in my providers’ notes is “LBP.”
What’s your first intuition? It seems it’s just as likely to be “low back pain” or “low blood pressure.” Not a fan.
Really great example….LBP can always be a tricky one! While ideally the abbreviation should have a straightforward interpretation, I’m with Erin that I would need to use the overall documentation of the note by utilizing the exam title when making that interpretation or incorporating the context of the note to make that decision and, if clarification is still needed, reaching out to the provider.
I would look for clues to determine what the doctor means. For instance, if it says LBP and the doctor orders a lumbar spine x-ray, I would go with low back pain. If it isn’t clear, I would query the provider.
Hi Erin -I agree that these practices help in obtaining the correct meaning of the abbreviation…and you are spot on that when you’re still not sure, query the provider. I think doing this also helps bring certain abbreviations to the providers attention they may not know are challenging or ambiguous.
I was hoping to see the author recommend that providers who use an EHR implement ‘dictionary’ tools that auto-expand that provider’s frequently used abbreviations into full terms. While it might be/might’ve been a reasonable, efficient practice to rely on standardized abbreviations and acronyms in handwritten notes, it doesn’t seem appropriate in an EHR with tools to avoid them. Since implementation of EHRs, I’ve seen an increase in ad hoc acronyms/abbreviations to the point where documentation is often (bloated, repetitive) acronym soup. I do miss that now defunct Joint Commission (inpatient) standard that required the principal diagnosis to be well-differentiated and free of abbreviations.
Hi Kim, fantastic point about the EHR dictionary tools out there. Ideally overtime as practices and organizations transition from paper to electronic records it would be great to see these tools utilized to their full potential. You mention the old inpatient standardization requirement . Ultimately once everyone gets on the same level of utilizing electronic records, use of tools such as the ones you mention could become standard practice.
great post