Objective: To assess frequency, nature and understanding of abbreviations in medical records.
Design: Audit of abbreviation use and meaning in paediatric handover sheets and medical notes compared against two standards, the Trust Intranet Medical Dictionary (TID) and Mosby’s Medical Dictionary (MMD). A selection of abbreviations was shown to health care professionals to examine interpretation of abbreviations.
Setting: Large inner-city district general hospital, Birmingham, UK
Main Outcome Measures: Frequency, nature and understanding of abbreviations in paediatric medical records.
Results: On 25 handover sheets a total of 2286 abbreviations were used, with 221 different abbreviations; the standards recognised 14% (TID) and 20% (MMD) of these abbreviations. In 168 sets of medical notes a total of 3668 abbreviations were used, with 479 different abbreviations; the standards recognised 15% (TID) and 17% (MMD). Some words were shortened in different forms, e.g. normal (N, Nl, NAD) and some abbreviations had multiple interpretations to those intended e.g. TOF (tetralogy of Fallot, tracheo-oesophageal fistula). When presented with a selection of abbreviations paediatric doctors recognized 56-94% and other health care professionals recognised 31-63%.
Conclusion: Abbreviation use was widespread in paediatric note keeping. There was no systematic approach to this and difficulties in interpretation were demonstrated. The use of standardised abbreviations to avoid confusion is suggested.
- Medical Records