abbreviations , acronyms , symbols and dose designations will be used . Abbreviations on the unapproved abbreviations and / or symbols list as set forth below may not be used .
b . Certain Abbreviations Prohibited . I .
General Rule . Certain abbreviations have been associated with medication errors and shall not be used . If a Member uses a prohibited abbreviation in a documented order , the order will not be carried out until the Member has been contacted and the order clarified . The prohibited abbreviations are as follows :
Abbreviation
Preferred Term U , u Write “ unit ” IU Write “ International unit ”
Q . D ., QD , q . d ., qd , Q . O . D ., QOD , q . o . d ., qod
Trailing zero ( x . 0 mg ) Lack of leading zero (. X mg ) MS MSO4 and MgSO4
Write “ daily ” Write “ every other day ”
Write X mg Write ( 0 . X mg ) Write “ morphine sulfate ” Write “ magnesium sulfate ”
II .
III .
Exception to General Rule . If , in the judgment of the Hospital staff providing care to the patient ( e . g ., the registered nurse , pharmacist , etc .), an order that includes a prohibited abbreviation is nonetheless clear and complete and a delay to obtain confirmation from the ordering Member prior to execution of the order would place the patient at greater risk , then the order may be carried out ; and the confirmation obtained as soon as possible thereafter .
Repeated Use of Prohibited Abbreviations . Repeated use of prohibited abbreviations by a Member is considered a patient safety issue . Such conduct will be reported in the Member ’ s file , should be grounds for appropriate action consistent with the Bylaws and Credentials Manual .
RULE 3-4 A .
Content of the History and Physical Examination
Focused History and Physical Examination : For patients undergoing an outpatient procedure under moderate sedation , a focused history and physical may be done in place of a complete H & P . This focused H & P should include :
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