I work in Compliance and we are having a discussion in regards to the use of abbreviations in the medical note. Of course, being in the medical field we all know what the common abbreviations are, but what if someone is reading the note and they don’t have the medical background. We are struggling to find any guidelines in regards to abbreviations. Is there any guidelines out there that state what abbreviations can be used and cannot be? The Joint Commission has a short list in regards to medication terms.

Thank you in advance for any help or advice you can give.

Ruby