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Original article
Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record
  1. Uri Hamiel1,2,
  2. Idan Hecht2,3,
  3. Achia Nemet2,3,
  4. Liron Pe’er2,3,
  5. Vitaly Man4,
  6. Assaf Hilely5,
  7. Asaf Achiron2,3
  1. 1Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin, Israel
  2. 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
  3. 3Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel
  4. 4Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University, Beer Sheva, Israel
  5. 5Department of Ophthalmology, Kaplan Medical Center, Rehovot and the Hebrew University of Jerusalem-Hadassah Medical School, Jerusalem, Israel
  1. Correspondence to Dr Uri Hamiel, Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin 70300, Israel; urihamiel{at}gmail.com

Abstract

Aims Abbreviations are common in the medical record. Their inappropriate use may ultimately lead to patient harm, yet little is known regarding the extent of their use and their comprehension. Our aim was to assess the extent of their use, their comprehension and physicians’ attitudes towards them, using ophthalmology consults in a tertiary hospital as a model.

Methods We first mapped the frequency with which English abbreviations were used in the departments’ computerised databases. We then used the most frequently used abbreviations as part of a cross-sectional survey designed to assess the attitudes of non-ophthalmologist physicians towards the abbreviations and their comprehension of them. Finally, we tested whether an online lecture would improve comprehension.

Results 4375 records were screened, and 235 physicians responded to the survey. Only 42.5% knew at least 10% of the abbreviations, and no one knew them all. Ninety-two per cent of respondents admitted to searching online for the meanings of abbreviations, and 59.1% believe abbreviations should be prohibited in medical records. A short online lecture improved the number of respondents answering correctly at least 50% of the time from 1.2% to 42% (P<0.001).

Conclusions Abbreviations are common in medical records and are frequently misinterpreted. Online teaching is a valuable tool for physician education. The majority of respondents believed that misinterpreting abbreviations could negatively impact patient care, and that the use of abbreviations should be prohibited in medical records. Due to low rates of comprehension and negative attitudes towards abbreviations in medical communications, we believe their use should be discouraged.

  • medical abbreviations
  • ophthalmology
  • medical errors
  • medical education

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Footnotes

  • Contributors UH, IH and AA led the study, were responsible for the study design, supervised the collection of data and analysis, and are the guarantors of the article. AN, LP, VM and AH were involved in data collection and helped with the literature review. IH and AA analysed the data. UH, AN, LP, VM and AH reviewed the data analysis. UH, IH and AA wrote the majority of the paper and were assisted by AN, LP, VM and AH. All authors approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Detail has been removed from this case description/these case descriptions to ensure anonymity. The editors and reviewers have seen the detailed information available and are satisfied that the information backs up the case the authors are making.

  • Ethics approval The study was performed following all the guidelines for experimental investigations required by the Institutional Review and Ethics Committee of the Edith Wolfson Medical Center.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Raw data of this study are available by personal request to the authors.

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