Objective To assess the understanding of commonly used abbreviations in the medical records among healthcare professionals.
Methods A selection of abbreviations from surgical inpatient admissions (gathered over a 10 day period in October 2008), in the form of a standard questionnaire, was shown to different members of a multidisciplinary team to examine interpretation and knowledge.
Results 209 questionnaires were analysed. The average correct response was 43%. Foundation Year 1 (F1) doctors scored the highest with 57% correct responses, whereas dieticians fared worst (20% correct). Among different abbreviations, NAD (91%) and SCBU (93%) were most often correctly answered, whereas CIC (3%) and STS (0.5%) were the most incorrectly answered. Certain abbreviations which are mostly used by nurses (eg, OTT) achieved a 75% correct response by them compared to only 11% by F1 and 10% by F2 doctors (p<0.001). Similarly, abbreviations such as COBH (p=0.025) and LUTS (p<0.001), although mostly correctly answered by junior doctors, were very poorly answered by nurses.
Conclusion The majority of healthcare professionals have a very poor knowledge of commonly used abbreviations. Use of unambiguous and approved list of abbreviations is suggested in order to ensure good communication in patient care.
- short form
- general medicine (see internal medicine)
- health & safety
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Abbreviations are commonly used in medical records to save time and space. Abbreviations can be confusing and may convey different meaning in different contexts (eg, DOA is interpreted as either ‘date of admission’ or ‘dead on arrival’ by different disciplines). The General Medical Council's (GMC) ‘Good Medical Practice’ advice to doctors is to keep clear, accurate and legible medical records in order to provide good clinical care to patients.1 The Nursing and Mid-wifery Council recommends that records should be factual and not include unnecessary abbreviations, jargon, meaningless phrases or irrelevant speculation.2 Abbreviations can be challenging and at times hazardous, especially in the context of drug prescription (eg, MS might be interpreted as magnesium sulfate instead of morphine sulfate or vice versa, with potential disastrous consequences). The Joint Commission on Accreditation of Healthcare Organizations, a US agency, found that nearly 5% of all errors were attributable to abbreviations. Consequently, they have published a ‘do not use’ list of abbreviations in order to reduce such errors.3
The introduction of the Data Protection Act in 1998 has granted access to one's own records (manual and computerised).4 This highlights the need to avoid using such confusing abbreviations which can have important medico-legal consequences. Use of abbreviations in the patients' copy of letters to general practitioners (GPs) may cause distress to patients or relatives, especially if they are misinterpreted. Medical defence organisations such as the Medical Defence Union (MDU) advise doctors to use only the abbreviations that are unambiguous and approved in their practice or hospital.5 The Royal College of General Practitioners has published an online directory listing some of the main abbreviations and denotations that may be used in patient medical records,6 although there are no other guidelines or approved list of abbreviations either by the Department of Health or by the professional bodies such as the GMC, to be used in the hospital records. The purpose of this study was to assess the understanding of abbreviations used in surgical case notes among a wide range of healthcare professionals at South Devon Healthcare NHS Trust.
We conducted a cross-sectional observational study on the use of abbreviations in randomly selected general surgical inpatient medical records at our hospital (n=50).
Definition of abbreviation
Abbreviation was defined as any shortened form of word or phrase—for example, Dr (Doctor)—or an acronym (words formed from initial letters)—for example, CAP (community acquired pneumonia)—or a contracture like C diff (Clostridium difficile) or an initialism (formed using initial components of a phrase or name)—for example, GMC (General Medical Council).7
Generation of a list of abbreviations
Five sets of inpatient surgical patient notes were reviewed every day to identify abbreviations over a 10 day period in October 2008. A total of 50 sets of notes were reviewed. The various components of the case notes reviewed were clinic letters, GP referral letters, junior doctors' clerking and allied health professional's notes (eg, nurses, dieticians, physiotherapists, pharmacists, and cccupational therapists). A total of 100 abbreviations were identified from case notes, out of which 30 abbreviations were selected by the authors which included abbreviations used by medical doctors, nursing and allied health staff so as to have a broad range. Each abbreviation and its proposed meaning in the context and professional group using it were recorded. A questionnaire about the use of abbreviations was constructed using these 30 abbreviations. These abbreviations were shown in context with the clinical notes to help correct interpretation—for example, Mr X is OTT. The correct meaning of these abbreviations was confirmed by consultation with the corresponding staff groups.
The questionnaire was circulated among a wide range of healthcare professionals such as foundation year 1 and 2 doctors (F1, F2), senior house officers (SHO), registrars, consultants, nurses, pharmacists, physiotherapists, dieticians, and medical secretaries. The professional group and grade of the participant was recorded. The participants were asked to document their interpretation of these abbreviations. The questionnaires were personally distributed and collected. Each questionnaire sheet was individually marked for correct and incorrect answers by the authors. Blank answers were considered as incorrect.
These data were entered into Microsoft Excel, 2007. Association between professional groups were assessed using χ2 tests and correct interpretation of abbreviations was carried out using SPSS version 15 (SPSS).
A total of 225 questionnaires were distributed. Two hundred and sixteen questionnaires were completed and returned (96%). Seven questionnaires were excluded as they were incomplete. Two hundred and nine questionnaires (93%) were included in the study. Among different healthcare professionals participating there were 27 F1, 41 F2 and SHOs, 23 registrars, 30 consultants, 36 nurses, 15 pharmacists, 12 physiotherapists, seven dieticians, and 18 medical secretaries. The overall correct response was 43%. F1 doctors scored the maximum with 462/810 (57%, 95% CI 53.6% to 60.4%) correct responses followed by registrars with 366/690 (53%, 95% CI 49.3% to 56.8%) and F2/SHOs with 668/1260 (53%, 95% CI 50.3% to 55.8%). In comparison to junior doctors, consultant surgeons scored only 414/900 (46%, 95% CI 42.7% to 49.3%) correct responses, whereas nurses performed poorly with 324/1080 (30%, 95% CI 27.3% to 32.7%) correct responses. Dieticians and medical secretaries scored the least number of correct responses, 44/210 (21%, 95% CI 15.4% to 26.5%) and 140/540 (26%, 95% CI 22.2% to 29.6%), respectively (table 1). Among different abbreviations, NAD with 188/209 correct (91%, 95% CI 87.0% to 94.8%) and SCBU with 194/209 correct (93%, 95% CI 89.3% to 96.3%) were the most correctly answered, whereas CIC with 6/209 correct (3%, 95% CI 0.6% to 5.1%) and STS with 1/209 correct (0.5%, 95% CI 0.0% to 1.4%) were the most incorrectly answered (table 2).
Certain abbreviations, mostly used by nurses (eg, OTT), achieved a 75% correct response by them compared to only 11% by F1 and 10% by F2 doctors (p<0.001). Similarly, abbreviations such as COBH (p=0.025) and LUTS (p<0.001), although mostly correctly answered by junior doctors, were very poorly answered by nurses (figure 1).
This study reflects the extent to which different healthcare professionals interpret abbreviations correctly. The overall correct response was only 43%, indicating a poor understanding of abbreviations by the majority of healthcare professionals. Junior doctors (F1, F2, SHOs, and registrars) scored more correct answers, probably because they work in a variety of places and are more aware of the different abbreviations used by different healthcare professionals. In contrast, consultants, nurses, and other allied healthcare professionals are usually exposed to only limited areas of their specialty.
A study by Parvaiz et al showed that common orthopaedic abbreviations were better answered by orthopaedic surgeons compared to members of other specialties.8 Our study revealed similar findings, that specific abbreviations were better answered by professionals using them more often in their regular practice—for example, OTT (out to toilet) was correctly answered by more nurses compared to junior doctors. Correspondingly more junior doctors answered LUTS (lower urinary tract symptoms) correctly compared to nurses (figure 1).
Use of abbreviations is widespread in medical records and may be a cause of concern.9 A study by Sheppard et al showed widespread use of abbreviations in paediatric notes as well as in handover sheets.10 In another study in an Australian tertiary paediatric centre, it was found that communication was hindered by use of abbreviations in progress reports and that overall comprehension of written information was only fair to average.11 Misinterpretation of abbreviations may also result in poorer outcome. Carroll et al in their study in a neonatal intensive care unit in the USA showed misinterpretation of abbreviations leading to documentation error resulted in longer hospital stay.12
Many different strategies have been used in the past to eliminate unsafe abbreviations,13–15 including the suggestion to make the meaning of abbreviations widely available to healthcare professionals.16 However, this approach has some limitation. For example, if an abbreviation is in common use by different disciplines, with more than one meaning, such abbreviations cannot be used officially. Others introduced the ‘Do not use’ list of abbreviations in relation to drug prescriptions.3 We believe that while it is impossible to expect healthcare professionals not to use abbreviations altogether, their use should be kept to an absolute minimum for effective and safe communication in patient care. Abbreviations should be avoided completely especially in drug prescriptions, theatre listing forms, operation lists and consent forms—for example, the laterality of site of operation.
We propose that each trust should establish lists of approved abbreviations and their correct meaning along with a list of ‘Do not use’ abbreviations to be followed by the healthcare professionals.
Use of abbreviations in medical records is widespread, although the majority of doctors, nurses and allied healthcare professionals have demonstrated a very poor knowledge of the correct meaning.
Each Trust should encourage its personnel to use an unambiguous and approved list of abbreviations in order to ensure good communication in patient care.
Current research questions
Does education of the healthcare professionals result in minimising the usage of abbreviations and improve the quality of documentation in hospital records?
Does implementation of ‘do not use‘ and/ or ‘approved’ list of abbreviations in the Trusts improve the quality of documentation in hospital records?
We would like to thank Dr Steve Shaw, Senior Lecturer in Statistics, School of Computing and Mathematics, University of Plymouth, of Plymouth for his help in data analysis.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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