Aim To identify the frequency and to assess the interpretation and validity of abbreviations used in the medical and surgical notes.
Methods A prospective audit was conducted collecting data regarding the use of abbreviations and intended meanings in the paediatric medical and surgical admission notes, these were then compared to a standard; the Mosbys medical dictionary. A sample of recorded abbreviations was then presented to a group of healthcare professionals to assess their interpretation.
Results A total of 1379 abbreviations were found in 113 sets of notes, 71 of these medical and 42 surgical. 15.2% were recognised as valid abbreviations by the Mosbys medical dictionary. In the medical notes 15.6% of abbreviations were found to be valid in comparison to 8.3% in the surgical notes. The average number of different abbreviations used per set of notes was 12.2. Consultants used the least with paediatric consultants using an average of 4.1 and surgeons 1.0. Junior doctors (F1-ST3) implemented the highest number; general paediatric doctors used an average of 7.2 abbreviations of which 15.4% were valid and surgeons 2.6 of which 1.1% were valid. When presented with a list of abbreviations Paediatric doctors were able to correctly identify 27–73% of abbreviations, other healthcare staff identified 33–40%. Paediatric surgeons scored and average of 51.1% compared to paediatricians who scored 37.3% and medical students 35.6%. Some commonly used abbreviations were interpreted differently by different specialties for example ARM was identified as artificial rupture of membranes by paediatricians and ano-rectal malformation by paediatric surgeons. Similarly paediatric staff recognised AF as anterior fontanelle while general medics identified it as atrial fibrillation. The abbreviation ‘SS’ had the intended meaning of septic screen however was interpreted more frequently as social services and soft solids.
Conclusion Abbreviations are a necessary and widely used component of medical note keeping however the majority do not conform to a standard and are susceptible to misinterpretation. This can lead to suboptimal patient care through mismanagement and consequently increased hospital stays. The use of a trust standard is suggested to avoid misunderstanding.