Standard MOI.4: The hospital uses standardized diagnosis and procedure codes and ensures the standardized use of approved symbols and abbreviations across the hospital.
In the 6th Edition, language was added to the intent and measurable elements of Standard MOI.4 to help clarify requirements related to the use of diagnosis and procedure codes, symbols, and abbreviations. In addition, a new measurable element was added, which prohibits the use of abbreviations in informed consent forms, patient rights documents, discharge instructions, and other documents patients and families receive from the hospital.
Standardization and uniform use of codes, symbols, and abbreviations can improve communication and understanding between health care practitioners, leading to safer and more effective care for patients. Appropriate use of abbreviations is particularly important. Numerous studies have focused on health care practitioners’ understanding and interpretation of abbreviations in medical documents, such as medical records, discharge summaries, and medication orders. Findings indicate that it is not uncommon for practitioners to have difficulty understanding the abbreviations used in their hospitals.
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