The Ultimate Guide to Dermatology Abbreviations

Abbreviations can seem like a real gift in a healthcare practice, where many of the words you commonly use are long and the time to add them to the notes is short. But without some kind of standard policy for their use, abbreviations can lead to confusion and even to dangerous medical errors.

Why Your Dermatology Practice Needs an Abbreviation Policy

The risk of staff using nonstandard abbreviations rises when practices have to recruit outside the medical field. The global dermatology market is expected to nearly double by 2034, with the fastest growth in North America. At the same time, a global shortage of healthcare workers makes recruitment challenging. As practices recruit nonclinical staff from a range of experiences, their familiarity with common dermatology terms cannot be assumed.

Even within clinical staff, you may find clinicians of different generations, different educational backgrounds, or different clinical experience using different abbreviations for the same thing. For example, there have been so many instances of morphine sulfate being administered instead of magnesium sulfate because the abbreviation was misunderstood, The Joint Commission put the two drugs on its list of terms that should never be abbreviated.

How to Create an Abbreviation Policy for Your Clinic

In creating your medical practice’s abbreviation policy, be sure to cover five things:

• When it’s OK to use abbreviations and when full terms should be spelled out. For instance, you may give staff permission to use abbreviations in a medical chart, but any communications that will be presented to the patient should have words spelled out in full.
• A practice-specific glossary of abbreviations. Make sure it is kept up to date and is easily accessible to everyone in the practice. Your dermatology EHR can be a great place to maintain this list so that everyone can see updates in real time. When possible, use the industry standard abbreviations, so clinicians outside your practice can understand your patient’s health record.

• A “never use” list of potentially confusing abbreviations. Practices that adhere to never using specific abbreviations have significantly less confusion. Start with the list from the Joint Commission:

• Regular staff training. Educate your staff on the dangers of using ambiguous and nonstandard abbreviations. Conduct regular refresher training on the approved abbreviation list and on the list of abbreviations to never use.

• Regular document audits. Conduct regular spot checks of practice documents to identify ambiguous abbreviations. When you find them, point them out and remind your staff why it’s important to follow the practice guidelines.

How to Use Your EHR to Avoid Abbreviation Confusion

A dermatology-specific EHR can reduce the risks of confusing abbreviations in your practice. Integrated real-time safeguards can trigger notifications when a nonstandard entry is made, or can offer in-line clarification of practice-specific terms.

Your EHR is customizable to your practice, making it easy to keep documents in line with your clinic policies. You can add practice-specific abbreviations, restrict data entry to only accept approved abbreviations, and flag any abbreviations on the “do not use” list.

The primary reason people use abbreviations is to save time. A specialty-specific EHR eliminates the need to abbreviate, with built-in dermatology templates pre-populated with common diagnoses, procedures, and treatment plans. When choosing the right term is as quick as point-and-click, clinicians are less tempted to apply their personal form of shorthand.

Common Abbreviations Used in a Dermatology Practice

Note: The following list is representative of many common abbreviations used in dermatology practices. It is not intended to be comprehensive.

Abbreviations for Dermatology Conditions

• AA: alopecia areata
• AFX: atypical fibroxanthoma
• AGEP: acute generalized exanthematous pustulosis
• AK: actinic keratosis
• ALM: acral lentiginous melanoma
• BCC: basal cell carcinoma
• BP: bullous pemphigoid
• CARP: confluent and reticulated papillomatosis
• CCCA: central centrifugal cicatricial alopecia
• CTCL: cutaneous T-cell lymphoma
• DLE: discoid lupus erythematosus
• DSAP: disseminated superficial actinic porokeratosis
• EM: erythema multiforme
• FFA: frontal fibrosing alopecia
• GA: granuloma annulare
• HS: hidradenitis suppurativa
• ILVEN: inflammatory linear verrucous epidermal nevus
• KA: keratoacanthoma
• KP: keratosis pilaris
• LMM: lentigo maligna melanoma
• LP: lichen planus
• LPP: lichen planopilaris
• LS: lichen sclerosus
• LSC: lichen simplex chronicus
• MF: mycosis fungoides
• MM: malignant melanoma
• NMSC: non-melanoma skin cancer
• PG: pyoderma gangrenosum / pyogenic granuloma
• PLEVA: pityriasis lichenoides et varioliformis acuta
• SCC: squamous cell carcinoma
• SK: seborrheic keratosis

Abbreviations for Dermatology Treatments

• QAM: once per day, in the morning
• QHS: once per day, at night
• BID: twice per day
• TID: three times per day
• PRN: as needed
• PO: by mouth
• IL: intralesional
• TOP: topical
• UNG: ointment
• CRM: cream

Abbreviations for Dermatology Procedures

• Bx: biopsy
• ExC: excisional curettage
• ED&C: electrodessication and curettage
• Mohs: Mohs micrographic surgery
• I&D: incision and drainage
• LN2: liquid nitrogen
• PDT: photodynamic therapy
• PUVA: psoralen + UVA
• NB-UVB: narrowband ultraviolet B

Abbreviations for Clinical Documentation

• C/D/I: clean/dry/intact
• c/w: consistent with
• f/u: follow-up
• FSE: full skin exam
• hx: history
• OV: office visit
• Pt: patient
• s/p: status post
• tx: treatment
• WNL: within normal limits

Make Abbreviations Work in Your Dermatology Practice

It’s human nature to try to be efficient, particularly when trying to see and process a high patient volume every day. Be aware, both clinical and office staff are going to use abbreviations that make sense to them in an effort to make their work move faster.

Creating a policy that spells out which abbreviations to use, which to avoid, and when to use them enhances productivity while dramatically reducing the risk of confusion that can lead to medical errors.

Using a dermatology-specific EHR that’s built for operational efficiency makes sure your policy is enforced, maximizing staff productivity without reducing patient satisfaction or safety. Request a demo today to see how Nextech’s EHR can help your team document faster, stay compliant, and avoid costly mistakes.