In medical documentation, what is preferred over the use of abbreviations?

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In medical documentation, the use of complete words and phrases is preferred over abbreviations to ensure clarity and avoid misunderstandings. Medical environments often require precise communication, as incomplete or abbreviated terms may lead to confusion or misinterpretation of critical information. Using full terminology reduces the risk of errors, especially in situations where multiple interpretations of an abbreviation could arise.

For example, terms like "hypertension" instead of "HTN" provide a clear understanding of the condition being referred to. This practice also helps maintain consistent documentation standards across different healthcare professionals who may not be familiar with specific abbreviations.

Furthermore, relying on complete words and phrases can enhance the overall quality of the medical record, making it easier for all parties involved – including other healthcare providers, patients, and legal representatives – to comprehend the documentation without having to decipher abbreviations.

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