Select Page


Inquiring Minds Want to Know


By Audrey Kirchner, CHDS


Transcription of pharmacological information is one of the most critical areas in healthcare documentation.  This is an area where we most often find critical errors and major errors.  Let’s examine some of the commonly
asked questions for this specialty.


Question:  I changed the abbreviation dictated “q. day” to daily.  Why was I marked wrong?


Answer:  The dangerous abbreviations list (located at BOS 9.3.1) gives us a list of very specific abbreviations that should be expanded.  If we look for an abbreviation “q day,” we will see that it is not on
the list.  Oftentimes, this is confused with the abbreviation dictated “q.d.”   That is why it was marked as an error.  The abbreviation q. day is not a dangerous abbreviation and should be
left exactly as dictated. 


Tip: List for the long “aaay” sound in q. day rather than the “dee” sound of q.d.


Question:  I typed in KCL for the medication that was dictated.  Why was that wrong?


Answer:  The medication name KCl is a unique one.  It is derived from the chemical elements for potassium (K) and chloride (Cl) and stands for potassium chloride.  Thus, it is a lowercase “l”
as in light.


Question:  I typed “Tylenol No. 3 1-2 tablets q.6 h.,” and it was marked wrong.  Why?


Answer:  Most companies and facilities encourage us to always type things in such a manner as to avoid misinterpretation.  When we have numbers that follow each other, it becomes imperative that we have ease
of reading and thus less chance of misinterpretation.  Tylenol No. 3 is the name of a medication (by the way, not Tylenol #3 because it is the medication’s actual name as No. 3).  We either need to recast the sentence
or change one of the numbers to a word rather than a number.  Thus, we would note as Tylenol No. 3 one to two tablets q.6 h.  Some might also accept simply inserting a comma, noting as Tylenol No. 3, 1-2 tablets
q.6 h.  Either way, there would be less chance of misinterpretation and a wrong dosing.


Question: I don’t understand why some medications are capitalized and some are not!  Help.


Answer:  This falls under the heading of drug classifications.  Brand name drugs are a proprietary name that a manufacturer has given to the drug.  It also comes with a trademark.  The
generic version of the drug is the nonproprietary name and is the established, official name for the drug.  That being said, aspirin is the generic form of the medicine but Bayer Aspirin is a brand-name version of that drug.  Every
drug that has a brand name always has a generic name and these are easily distinguishable if you use a website such as or even if you Google search.  It is important to note a drug
correctly as generic or brand name with capitalization because the HDS must know the difference.  When we do it incorrectly, this raises doubt as to the accuracy of the medication transcribed.  For instance, if
we type in “The patient was given Lisinopril on discharge,” it can be questioned whether we heard the right medication or if the dictator dictated about a brand-name drug starting with a capital “L.”  Take that extra moment or two
to double check every medication to get it correctly noted!  You’ll also learn to associate generic drugs with their brand name equivalents.  (See BOS 13.2.2 for more information on Drug Naming and Classification)


Question:  I typed in exactly what was dictated as “He was given tamsulosin .4 mg (point-four milligrams) and I got it wrong.  It is verbatim, so why is this wrong?


Answer:  If we go back to our dangerous abbreviations list, we find the section on trailing zero and lack of leading zero.  This gives us explicit instructions on what to do regarding 0’s before and after a decimal
point. If the number is less than 1 and contains a decimal point, then we must add a 0 (leading zero), with the only exception being caliber of weapons.  (For weapons, we would note as a .22 pistol.)  For everything
else, we would add that zero to avoid it being misread.  For example, .4 mg could be read incorrectly as 4 mg.  Thus, for clarity and assuring proper documentation of dosing, we note as 0.4 mg.  Then
there is no doubt that the dosing is correctly noted.  (See BOS 9.3.1 for more on Trailing zero and Lack of leading zero).


Question:  I typed in verbatim what was dictated as “Estimated blood loss was 250 cc” and it was marked wrong.  I don’t understand!


Answer:  This is also a dangerous abbreviation and we are given the directive by the Joint Commission to change this to mL automatically even when dictated as “cc.”  There are many medication or dose-associated
abbreviations on that list so be sure and print it out and keep it handy as a reference.  We note it as mL because it can be misinterpreted for U (which could mean units) if it is not clearly typed by certain fonts or handwritten
inappropriately.  It stands for cubic centimeter but do keep in mind that it only pertains to liquid measures and not mass.  That means that if you are talking about a prostate or a breast measurement in terms of
cubic centimeters, it would remain cc, whereas a blood loss is a liquid measure or topical anesthesia is a liquid measure so both would be changed to mL.


Question:  Wouldn’t it just be simpler to write out all Latin abbreviations in dosings so that it would be uniform?  Why can’t just expand all such as b.i.d., q.i.d., et cetera?


Answer:  The Joint Commission has and always will determine those abbreviations that have been proven to cause misinterpretation in the practice of medicine.  Some abbreviations are more prone to misinterpretation
and that is why they are on the list.  However, other abbreviations such as p.r.n., q.i.d., p.o. q.4-6 h. and q.a.m. are much more easily interpretable as abbreviations (the ultimate goal achieved as ease of reading and quick interpretation)
and so they should remain as dictated.  Unless you are given direct instructions via a client’s account specifics to expand other abbreviations, you would only expand those that are on the list, which usually also includes the ISMP
Recommendations (BOS 9.3.2).  Documentation’s main purpose is to make medical records easy to interpret accurately and in a timely fashion.  We use abbreviations to help achieve that goal and only when they are
considered dangerous to use do we need to change them.