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Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping
J E Sheppard1, L C E Weidner, S Zakai
1Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, UK.
Insights
Medical record abbreviations are common in pediatrics, but understanding is poor. Standardized abbreviations are recommended to prevent confusion and improve patient safety.
Area of Science:
- Medical Informatics
- Healthcare Communication
- Patient Safety
Background:
- Abbreviation use in medical records is prevalent.
- Lack of standardized abbreviations can lead to misinterpretation.
- Effective communication is crucial in pediatric care.
Purpose of the Study:
- To evaluate the frequency and nature of abbreviations in pediatric medical records.
- To assess the understanding and interpretation of these abbreviations by healthcare professionals.
- To compare abbreviation recognition against established medical dictionaries.
Main Methods:
- Audit of abbreviation usage in pediatric handover sheets and medical notes.
- Comparison of identified abbreviations with Trust Intranet Medical Dictionary (TID) and Mosby's Medical Dictionary (MMD).
- Survey of healthcare professionals to test their interpretation of selected abbreviations.
Main Results:
- A high volume of unique abbreviations were identified in pediatric records (221 in handover sheets, 479 in medical notes).
- Medical dictionaries recognized a low percentage of these abbreviations (14-20%).
- Paediatric doctors showed higher recognition rates (56-94%) than other healthcare professionals (31-63%), with instances of multiple interpretations for single abbreviations.
Conclusions:
- Widespread and unsystematic use of abbreviations in pediatric notes was observed.
- Significant difficulties in abbreviation interpretation were demonstrated.
- Standardization of abbreviations is crucial to mitigate confusion and enhance clarity in medical documentation.
Objective:
To assess the frequency, nature and understanding of abbreviations in medical records.
Design:
Audit of abbreviation use and meaning in paediatric handover sheets and medical notes compared to two standards, the Trust Intranet Medical Dictionary (TID) and Mosby's Medical Dictionary (MMD). A selection of abbreviations was shown to healthcare 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, for example, normal (N, Nl, NAD) and some abbreviations had multiple interpretations that differed from those intended, for example, TOF (tetralogy of Fallot, tracheo-oesophageal fistula). When presented with a selection of abbreviations, paediatric doctors recognized 56-94% and other healthcare 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.
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