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Policy No.:   D0209  

 

 
 
 

 

Spell it Out: Standardised terminology, 
abbreviations and symbols to be used 
when communicating about medicines 

Policy Directive 
 

Version No.:  3.0 
Approval date:  06/08/2018 

 

  



 
 

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Contents  
 
1. Policy Statement .................................................................................................................. 3 

2. Roles and Responsibilities .................................................................................................. 3 

3. Policy Requirements............................................................................................................ 4 

4. Implementation &amp; Monitoring ............................................................................................... 4 

5. National Safety and Quality Health Service Standards ....................................................... 5 

6. Definitions ............................................................................................................................ 6 

7. Associated Policy Directives / Policy Guidelines and Resources ....................................... 6 

8. Document Ownership &amp; History .......................................................................................... 6 

  



 
 

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Spell it Out: Standardised terminology, abbreviations 
and symbols to be used when communicating about 

medicines Policy Directive 
 
 

1. Policy Statement 

1.1 SA Health is committed to the Quality Use of Medicines (QUM). 

1.2 SA Health is committed to raising awareness to the importance of clear communication 
when prescribing, dispensing and administering medications, and when documenting 
medicines information. 

1.3 The purpose of this policy is to promote patient safety through the use of clear and 
unambiguous communication of medicines information based on the Australian 
Commission on Safety and Quality in Health Care s (the Commission s)  Recommendations 
for terminology, abbreviations and symbols used in medicines documentation  (the 
Recommendations) by establishing: 

? principles for safe, clear and consistent terminology for medicines 

? a set of recommended terms, acceptable abbreviations and dose designations for 

medicines. 

 

2. Roles and Responsibilities 

 

2.1 Chief Executive, SA Health will: 

? ensure SA public hospitals and health services are aware of and comply with this 

policy. 

2.2 Director, Medicines and Technology Programs, SA Health will: 

? establish, maintain and periodically review the effectiveness of the Spell it Out: 

Standardised terminology, abbreviations and symbols to be used when 

communicating about medicines Policy Directive 

? monitor and evaluate implementation of the directive at a Local Health Network 

(LHN) level through LHN reporting to the South Australian Medication Safety 

Advisory Group (SAMSAG) 

? provide advice to health services in response to specific queries regarding 

standardised terminology, abbreviations and symbols used in medicines 

documentation. 

2.3 Local Health Network and Statewide Services Chief Executive Officers will: 

? implement the policy directive and promote implementation of the principles and 

recommended terminology, abbreviations and dose designations into protocols, 

practices and educational programs within their area of control 

? delegate the day to day responsibility for complying with this policy to the relevant 

senior managers 

? ensure governance arrangements for medication management and medication 

safety include specific responsibility for the use of clear and unambiguous 

terminology, abbreviations and symbols when communicating about medicines. 

 



 
 

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2.4 Executive Directors, Directors, Heads of Service/Departments and other Senior 

Managers will: 

? ensure risks associated with the use of unsafe terminology, abbreviations and 

symbols when communicating about medicines are identified and assessed, and 

that actions to reduce identified risks are implemented and evaluated 

? promote staff awareness of the Commission s  Recommendations for terminology, 

abbreviations and symbols used in medicines documentation  

? ensure local policies and procedures are implemented for appropriate terminology, 

abbreviations and symbols used in medicines documentation 

? ensure incidents involving error-prone abbreviations, terminology and symbols are 

reported to the Safety Learning System (SLS) and via other appropriate pathways 

and managed in accordance with the Patient Incident Management and Open 

Disclosure Policy Directive. 

2.5 SA Health employees will: 

? ensure they are familiar with the Commission s Recommendations, including the: 

? principles for safe, clear and consistent terminology for medicines 

? list of safe terms, abbreviations and dose designations for medicines 

? ensure they comply with the principles and recommended terms, acceptable 

abbreviations and dose designations when prescribing, dispensing and 

administering medications and in medicines documentation 

? ensure incidents involving error-prone abbreviations, terminology and symbols are 

reported to the Safety Learning System (SLS) and via other appropriate pathways 

and managed in accordance with the Patient Incident Management and Open 

Disclosure Policy Directive. 

 

3. Policy Requirements 
 
3.1 Principles 

SA Health is committed to the Quality Use of Medicines (QUM) and to raising awareness to 
the importance of clear communication when prescribing, dispensing and administering 
medications, and when documenting medicines information. 

This policy promotes patient safety through the use of clear and unambiguous 
communication of medicines information based on the Commission s  Recommendations 
for terminology, abbreviations and symbols used in medicines documentation  by 
establishing: 

? principles for safe, clear and consistent terminology for medicines 

? a set of recommended terms, acceptable abbreviations and dose designations for 

medicines. 

3.2 Detail 

3.2.1 The principles for safe, clear and consistent terminology for medicines, acceptable 

terms, abbreviations and dose designations, including dose forms, units of measure 

and concentration, and routes of administration as outlined in the Commission s 

Recommendations must be adhered to for: 

? all medication orders or prescriptions that are hand written, pre-printed, 

computer generated (printed hard copy) or electronic 

? all communications and records concerning medication documentation, 

including local policies, protocols and procedures 



 
 

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? all labels for medicine storage. 

3.2.2 Before deciding to include additional terminology not listed in the Commission s 

Recommendations in local policies, the principles outlined in the Recommendations 

must be applied and a risk assessment undertaken. 

3.2.3 It is acknowledged that there may be potential limitations in utilising all the 

recommendations in the electronic environment. Where there is variation from the 

Recommendations, a risk assessment is recommended and where required, risk 

management strategies implemented. 

? In most cases, the Recommendations align with recommendations described 

in the National guidelines for the on-screen display of clinical medicines 

information and Australian Medicines Terminology. 

 
4. Implementation &amp; Monitoring 
 
It is the responsibility of LHNs to implement the principles of this policy and to monitor the 
outcomes. This may be achieved by assessing ongoing progress and performance by utilising the 
following indicators: 

? National Quality Use of Medicines Indicators for Australian Hospitals. Indicator 3.3: 

Percentage of medication orders that include error-prone abbreviations 

? National Inpatient Medication Chart Audit 

 

5. National Safety and Quality Health Service Standards 
 

 
Please note these National Standards above apply until 31 December 2018.  
 
The National Standards below will be implemented from 1 January 2019.  

 
 

National 
Standard 1 

 
Governance 

for Safety 
and Quality 

in Health 
Care 

 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 
 
 
 

 
 

National 
Standard 3 

 
Preventing 

&amp; 
Controlling 
Healthcare 
associated 
infections 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Patient 

Identification 
&amp; Procedure 

Matching 
 
 

 
 

National 
Standard 6  

 
Clinical 

Handover 
 
 
 

 

 
 

National 
Standard 7 

 
Blood and 

Blood 
Products 

 
 

 

 
 

National 
Standard 8 

 
Preventing 

 &amp; 
Managing 
Pressure 
Injuries 

 

 
 

National 
Standard 9 

 
Recognising &amp; 
Responding to 

Clinical 
Deterioration 

 
 

 
 

National 
Standard 10 

 
Preventing 

Falls &amp; 
Harm from 

Falls 
 
 

? ? ? ? ? ? ? ? ? ? 

 
 

National Standard 
1 
 

Clinical 
Governance 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 

 
 
 

 
 

National 
Standard 3 

 
Preventing &amp; 
Controlling 
Healthcare- 
Associated 
Infection 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Comprehensiv

e Care 
 
 

 
 

National 
Standard 6 

 
Communica

ting for 
Safety 

 
 
 
 

 
 

National 
Standard 7 

 
Blood 

Management 

 
 

National 
Standard 8 

 
Recognising &amp; 
Responding to 

Acute 
Deterioration 

 
 

? ? ? ? ? ? ? ? 




























































































































 
 

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The Medication Safety Standard aims to ensure clinicians are competent to safely prescribe, 
dispense and administer appropriate medicines and monitor medicines use, and patients and/or 
carers are informed regarding treatment options, benefits and associated risks. 
 
The Communicating for Safety Standard aims to ensure timely, purpose-driven and effective 
communication and documentation that supports continuous, coordinated and safe care for 
patients. 
 

6. Definitions 
 
In the context of this document: 

? Local policies means policies adopted in individual hospitals or health services. 

 
7. Associated Policy Directives / Policy Guidelines and Resources 
 
7.1 Patient Incident Management and Open Disclosure Policy Directive 

7.2 Australian Commission on Safety and Quality in Health Care (2016). Recommendations for     
terminology, abbreviations and symbols used in medicines documentation. ACSQHC, 
Sydney. 

7.3 Spell it out Standards. SA Health. Standardised terminology, abbreviations and symbols to 
be used when communicating about medicines. 

 

8. Document Ownership &amp; History 

Approval 
Date 

Version 
Who approved New /  
Revised Version 

Reason for Change 

06/08/2018 v 3.0  

Formally reviewed in line with 5 year 
scheduled timeline for review.  

? Policy detail unchanged 

? Commission reference document 
updated from original version 

? Transferred to new SA Health 
template. 

28/05/2013 v 2.0 OCE 
Minor amendment to reflect impact on 
EPAS and Branch name change 

28/02/2011 v 1.1 OCE 
Minor amendment - titles of regional CEOs 
to Local Health Network CEOs 

17/12/2009 v 1.0 Portfolio Executive Original PE approved version. 

 

Document developed by:  Medicines and Technology Programs 

File / Objective No.: 2009-15524  |  A850696 

Next review due:   01/06/2023 

Policy history: Is this a new policy (V1)?  N 

 Does this policy amend or update an existing policy version?   Y 

 If so, which version? v 2.0 

 Does this policy replace another policy with a different title?  N 

 If so, which policy (title)? N/A 

 

ISBN No.: 978-1-76083-036-6 

 

 








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