Joint Commission- Do Not Use Abbreviations..

Locate a copy of The Joint Commission’s Do Not Use Abbreviation (DNUA) list. Examine the sample transcription reports and compare them with the DNUA list. Determine any error(s) found that conflict with the DNUA list and recommend the necessary corrections.
Report 1
Procedure: Trigger Point Injection
Anesthesia: Local and MAC
Complications: None
Procedure: The 48-year-old white female was brought to the procedure suite. After reviewing the risks, benefits, and alternatives to the procedure, she decided to proceed with the trigger point injection. Her upper back was sterilely prepped. I isolated the muscle in spasm and used a 25-gauge 5-inch needle to perform an aspiration of the area, which was negative. Then 4.0 cc of Marcaine .5 percent was injected into three trigger points. She tolerated the procedure very well.

Report 2
Procedure: Right prepatellar bursal injection
Anesthesia: MAC
Complications: None
Procedure: this 57- year-old black male has acute prepatellar bursitis. The right knee is swollen and warm to the touch. He has had similar symptoms in the past, responded well to Aristopan injection, and is here today for an injection.
I reviewed the risk, benefits, and alternatives to the procedure with the patient, who expressed his understanding and agreed to proceed with the injection. MAC sedation was initiated and I prepped the knee with a sterile alcohol wipe. I then injected 20.0 mg of Artistospan into the right prepatellar bursa. No complications from the injection were noted. Discharge after criteria met. Instructed patient it was okay to continue his Novolog 100 U before each meal for this type I diabetes.

References:
Brodnick, M.S., L.A. Rinehart-Thompson, and R.B. Reynolds. 2012. Fundamentals
of Law for Health Informatics and Information Management, 2nd ed., revised
reprint. Chicago: AHIMA
Shaw, P.L. and D. Carter. 2015 Quality and Performance Improvement in
Healthcare, A Tool for Programmed Learning, 6th ed. Chicago: AHIMA