The Abbreviation That Changed the Dose
You are reviewing a paper chart before a patient's follow-up. The physician's handwritten note from the prior visit reads: 'Start Lasix 40 mg QD. Recheck K+ in 1 wk. Pt c/o SOB and 2+ edema BLE.' A second entry, added later the same day in different handwriting (likely a covering provider), reads: 'Increase to 80 QD.' There is no signature on the second entry, no date, and no clarification of whether '80' refers to mg or something else. The patient is on multiple medications, and the chart also lists a potassium supplement. The physician is unavailable, and the patient is due in 30 minutes. The front desk asks whether to just 'go with the 80' since that is the most recent note.
1. What are the documentation problems in this chart, and what should you do before the patient is seen?
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Problems:
- Unapproved abbreviations - 'QD' is on the do-not-use list because it can be misread as QID; 'BLE' and 'SOB' are common but should be spelled out in orders.
- Unsigned, undated entry - the '80 QD' note has no author, signature, or date, so it cannot be relied on as a valid order.
- Ambiguous dose - '80' without a unit is not a complete order.
- No clarification of intent - did the covering provider intend 80 mg daily, or was it a transcription of something else?
Before the patient is seen:
- Do not act on the '80' entry.
- Flag the chart for the physician or covering provider to clarify and sign.
- If the patient must be seen before clarification, have the covering provider review and rewrite the order with full drug name, dose, unit, route, frequency, and signature/date.
- Document that the ambiguous entry was identified and escalated.
2. The covering provider is reached and says the intent was 80 mg daily. How should the order be corrected, and what should you verify given the potassium supplement?
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Correction: the covering provider should write a new, complete order - 'Furosemide (Lasix) 80 mg by mouth once daily' - with date, time, and signature. The old ambiguous entry should not simply be edited over; it should be clarified with a dated addendum or a new order that references the clarification. Never alter another provider's entry without a documented addendum.
Potassium check: furosemide is a loop diuretic that can lower potassium, and the patient is also on a potassium supplement. Verify:
- The most recent K+ result and when it was drawn.
- Whether the supplement dose is still appropriate at the new diuretic dose.
- Whether the 'recheck K+ in 1 week' was actually scheduled and completed.
Flag any discrepancy to the provider before the patient leaves. The dose change and the potassium regimen interact, so this is not a routine refill.