Practice Management:
Avoid These Common Documentation Shortcuts
Published on Fri Nov 01, 2024
Question: I know illegibility has historically been an obstacle to good documentation. My practice uses electronic health records (EHR), but I still sometimes get confused when a provider writes QD versus QOD. Is there an alternative I can recommend so the documentation is clearer?
Minnesota Subscriber
Answer: EHRs are in use in most places now, so the stigma providers have long carried for their hard-to-read handwriting is losing steam. However, some medical shorthand is problematic regardless of readability. In fact, on its website, the Joint Commission mentions QD and QOD specifically on their “Do Not Use” List, which applies to all orders, preprinted forms, and documentation related to medication.
Here are some alternatives you can recommend.
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Abbreviation to Avoid
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Potential Problem
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Use Instead
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U, u (unit)
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Mistaken for 0 (zero), 4 (four) or “cc”
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Write “unit”
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IU (international unit)
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Mistaken for IV (intravenous) or 10 (ten)
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Write “international unit”
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Q.D., QD, q.d., qd (daily)
Q.O.D., QOD, q.o.d., qod (every other day)
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Reader may confuse the two meanings
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Write “daily” or “every other day”
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Trailing zero (X.0 mg)*
Lack of leading zero (.X mg)
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Decimal point may be missed
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Write “X mg” or “0.X mg”
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MS, MSO4 and MgSO4
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Can mean morphine sulfate or magnesium sulfate; reader may confuse the two meanings
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Write “morphine sulfate” or “magnesium sulfate”
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Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
