Abbreviations

Purpose

This policy ensures that all clinical records are accurate, consistent, and easily understood by patients, staff, and external reviewers. Standardized abbreviation use reduces the risk of misinterpretation, supports patient safety, and maintains compliance with regulatory and accreditation requirements.

Policy

Abbreviations must be clear, unambiguous, and widely recognized in healthcare practice. Staff are prohibited from using personal, improvised, or non-standard abbreviations that could compromise patient safety or record clarity.   

Process

Therapy documentation is reviewed as part of ongoing URQA and compliance efforts.   We will ask for corrections to meet regulatory criteria if the standard is not met.