HSE Code of Practice for Healthcare Records Management - Abbreviations

Sep 23, 2026

HSE Code of Practice for Healthcare Records Management provides agreed rules and examples for using abbreviations in healthcare records. It defines when abbreviations should be avoided, specifies formatting requirements such as Block Capitals, and lists items that must never be abbreviated, including resuscitation decisions, drug names, right/left, and consent or incident report forms. It also describes guidance for typed or pre-printed documentation and use of approved abbreviations for handwritten entries, supporting consistent, safer clinical communication.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages54

Reading Time2 h 16 min

AccessFree to download

Rules for abbreviations

Abbreviations should be avoided

Items that must never be abbreviated

Use in typed, pre-printed, and handwritten records

Drugs and Prescribing

Doses

Frequency of Administration

Days of the Week

Time Abbreviations

Routes of Administration

Prescribing electrolytes and trace elements

Interpretation of dose frequency

Approved abbreviations list for use in healthcare records

Notation for mobilisations and manipulations

Health Service Executive Code of Practice for Healthcare Records Management Abbreviations Date: June 2010 This is a controlled document and may be subject to change at any time Version 2.0 ReaDeR InfoRmatIon | Directorate: | Quality & Clinical Care Directorate | | --- | --- | | title: | HSE Code of Practice for Healthcare Records Management | | Document
Purpose: | Abbreviations | | Publication Date: | June 2010 | | target audience: | All staff in the HSE who work in healthcare records management | | Description: | This section is intended to encourage best practice while assisting healthcare professionals to make effective use of their time, by providing a list of agreed abbreviations, which are approved for use throughout the HSE | | Superseded Docs: | Version 1 June 2007 | | Review Date: | June 2012 | | Contact Details: | Winifred Ryan,
Quality & Clinical Care Directorate, Health Service Executive.
[Email: winifred.ryan@hse.ie](Email: winifred.ryan@hse.ie)[ ](Email: winifred.ryan@hse.ie)annmarie.heffernan@hse.ie [gay.murphy@hse.ie](gay.murphy@hse.ie)
Web: [www.hse.ie](www.hse.ie) | table of Contents Page 1. Rules for abbreviations 4 2. Drugs and Prescribing 7 2.1 Doses 8 2.2 Frequency of Administration 9 2.3 Days of the Week 10 2.4 Time Abbreviations 11 2.5 Routes of Administration 11 2.6 Prescribing electrolytes and 12 trace elements 2.7 Interpretation of dose frequency 13 instructions 3. approved abbreviations List for Use in Healthcare Records 15 4. notation for mobilisations and manipulations 53 1 . Rules for abbreviations 1.1 Abbreviations should be avoided if at all possible, but in the event of abbreviations being utilised, only those approved by the Quality & Clinical Care Directorate and contained within this document are permitted. 1.2 If an abbreviation is used that is not contained within this document the full term used, followed by the abbreviation in brackets, should be written on each side of each page. 1.3 All abbreviations must be written in Block Capitals (e.g. MI – Myocardial infarction) . Contractions can be expressed as a mixture of higher and lower case. Contractions used in this document omit the end of a word and are terminated with a full stop (e.g. , Ausc.– Auscultation) . 1.4 The following must neVeR be abbreviated. | never abbreviate decisions regarding resuscitation of a patient | Any decision regarding resuscitation of a patient must always be written in full and signed. A decision of such gravity must never be abbreviated. | | --- | --- | | never abbreviate drug names | Drug names must always be written in full and shall never be abbreviated under any circumstances. | | never use R and L | Right and left must be written in full. The exception to this rule is when right or left is contained within an abbreviation, e.g. LIF – left iliac fossa. | | +++, < less than and> greater than should be avoided except where they are part of an official grading system (i.e. urinalysis results) | Accepted grading systems should only be used | | --- | --- | | never use these symbols +ve and –ve | +ve and –ve are not acceptable. These can be abbreviated to Pos. and Neg. | | any reference to the service user/patient must never be abbreviated | The service user/patient’s given name should always be used. | | abbreviations must never be used on a consent form | | | abbreviations must never be used in the completion of incident report forms | | 1.5 Laboratory tests may be abbreviated on typed reports but only approved abbreviations contained within this document may be hand-written in service user/patient healthcare records. If an abbreviation is used that is not contained within this document the full term used, followed by the abbreviation in brackets, should be written on each side of each page. 1.6 Abbreviations pre-printed or typed on Health Service Executive documentation (and on computer) can remain unchanged, as they are generally und

FAQs

When can abbreviations be used in HSE healthcare records?

Abbreviations should be avoided where possible. If used, only abbreviations approved by the Quality & Clinical Care Directorate and contained in the document are permitted.

What must never be abbreviated?

Resuscitation decisions must always be written in full and signed. Drug names must never be abbreviated under any circumstances, right and left must be written fully (except within an abbreviation), and abbreviations must not be used on consent forms or in incident report forms completion.

How should time and dosing information be documented?

The 24-hour clock must be used for clinical documentation time. The document also provides sections for doses, frequency of administration, days of the week, time abbreviations, routes of administration, electrolytes and trace elements, and interpreting dose frequency.

Sep 23, 2026

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