Medical Charting Tips for Phlebotomy Technicians
When Making Entries into Medical
Charts...
- ALL ENTRIES in medical records must be LEGIBLE, DATED AND SIGNED including their professional title and
IDENTIFICATION so that any future reader can identify each entry's author.
- Avoid using problem prone abbreviations listed in the table below. Or better, do not use
abbreviations; if you must, use only abbreviations and symbols approved by your medical office, clinic, or
hospital.
- Use only approved chart forms with the patient's name, the date, and the time recorded on each sheet and
on, if applicable, both sides of every sheet in the record.
- Use ink; never pencil.
- Don't skip lines or leave spaces between entries.
- Don't use vague, non-descriptive terms.
- Don't get personal. Comments cannot be removed or changed. Refrain from entering into the chart any
statement that does not deal directly with the patient's diagnosis, treatment, care or condition.
- Don't use the medical record to comment on other health-care professionals or their actions.
- Don't wait until the end of the day to chart.
- Don't back date, add to or tamper with notes on the medical record.
- Don't use terms unless medical assistants know what they mean.
- Always legibly identify yourself by signature, or initials.
- All entries in the medical record must be signed by the author. Federal law mandates that only the author
can sign his/her entries in medical records.
Medical Charting Abbreviations and Meaning
| Abbreviation to Avoid |
Intended Meaning |
Misinterpretation |
Correction |
| D/C |
discharge discontinue |
Premature discontinuation of medication (intended to mean discharge) especially when
followed by a list of discharge medications. |
Use "discharge" and "discontinue" |
| MgSO4 |
Magnesium sulfate |
Morphine sulfate |
|
| MSO4 |
Morphine sulfate |
Magnesium sulfate |
|
| MTX |
Methotrexate |
Mitoxantrone |
|
| ZnSO4 |
Zinc sulfate |
Morphine sulfate |
|
| q.d. or QD |
every day |
Mistaken as q.i.d. especially if the period after the "q" or the tail of the "q" is
misunderstood as an "I". |
Use "daily" or "every day" If abbreviation is used, capitalize and avoid use of
periods. |
| q.o.d. or QOD |
every other day |
Misinterpreted as "qd"(daily) or "qid" (four times daily) if the "o" is poorly
written |
Use "every other day". If abbreviation is used, capitalize and avoid use of
periods. |
| U or u |
units |
Read as zero (0) or a four (4) causing a 10-fold overdose or greater (4U seen as "40"
or 4u seen as "44"). |
Unit has no acceptable abbreviations. Use "unit". |
| IU |
international units |
Misread as IV (intravenous) |
Use "units" |
| TIW |
three times a week |
Mistaken as "three times a day" |
Spell out "three times a week" |
| AU |
each ear |
Mistaken for OU "each eye" |
|
| SS |
sliding scale (insulin) mistaken |
for "55" |
Spell out "sliding scale" |
| Zero after decimal point 1.0 (trailing zero) |
1 mg |
Mistaken as 10 mg if the decimal point is not seen |
Do not use trailing zero's |
| No zero before a decimal dose .5 mg (no leading zero) |
0.5 mg |
Misread as 5 mg |
Always use zero before a decimal when the dose is less than a whole unit |
LEARNING TIP FOR NEW STUDENTS:
Practice both medical office and phone call
situations!
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