TY - JOUR
T1 - Analysis of abbreviations used by residents in admission notes and discharge summaries
AU - Shilo, L.
AU - Shilo, G.
N1 - Publisher Copyright:
© The Author 2017. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved.
PY - 2018/3/1
Y1 - 2018/3/1
N2 - Background: There are abbreviations that are used daily such as BP for blood pressure and ECG for electrocardiogram, but many of the abbreviations found in medical documents are unclear. Aim: The purpose of this study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents. Methods: Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The frequency of use of the abbreviations was determined. Additionally, the fifty commonest abbreviations from each specialty were graded by three medical and three orthopedic surgery senior physicians as 1. understandable or 2. Ambiguous or unknown. Results: The number of abbreviations found in the documents composed by medical and orthopedic surgery residents was 1525 with 80 different abbreviations and 493 with 51 different abbreviations respectively (9.3% and 4.9% of the total word number respectively). Analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians. Conclusion: In order to prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non standard abbreviations such as the incorporation of authorized abbreviations to the electronic medical record.
AB - Background: There are abbreviations that are used daily such as BP for blood pressure and ECG for electrocardiogram, but many of the abbreviations found in medical documents are unclear. Aim: The purpose of this study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents. Methods: Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The frequency of use of the abbreviations was determined. Additionally, the fifty commonest abbreviations from each specialty were graded by three medical and three orthopedic surgery senior physicians as 1. understandable or 2. Ambiguous or unknown. Results: The number of abbreviations found in the documents composed by medical and orthopedic surgery residents was 1525 with 80 different abbreviations and 493 with 51 different abbreviations respectively (9.3% and 4.9% of the total word number respectively). Analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians. Conclusion: In order to prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non standard abbreviations such as the incorporation of authorized abbreviations to the electronic medical record.
UR - http://www.scopus.com/inward/record.url?scp=85043477636&partnerID=8YFLogxK
U2 - 10.1093/qjmed/hcx241
DO - 10.1093/qjmed/hcx241
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C2 - 29237038
AN - SCOPUS:85043477636
SN - 1460-2725
VL - 111
SP - 179
EP - 183
JO - QJM: An International Journal of Medicine
JF - QJM: An International Journal of Medicine
IS - 3
ER -