Danger in discharge summaries: abbreviations create confusion for both author and recipient

The transition from hospital inpatient care to medical care in the community is a high-risk period for adverse events. Inadequate communication, including low-quality or unavailable discharge summaries, has been shown to impact patient care.

To assess use of abbreviations in clinical handover documents from inpatient hospital teams to general practitioners (GP), and the interpretation of these abbreviations by GP and hospital-based junior doctors.

This is a retrospective audit of 802 discharge summaries completed during a 1-week period in 2017 by a Queensland regional health service. GP and local junior doctors then attempted interpretation of 20 relevant abbreviations.

A total of 99% (794) discharge summaries included abbreviations. A total of 1612 different abbreviations was used on 16 327 occasions. The median number of abbreviations per discharge summary was 17 (range 0-86). A total of 254 GP and 62 junior doctors responded to a survey, which found that no abbreviation was interpreted the same by all respondents. GP and junior doctors were unable to offer any interpretation in 17.9% and 15.2% of cases respectively. GP offered a greater range of interpretations than junior doctors, with a median of 9 and 3 different interpretations per abbreviation respectively. A total of 94% (239) of GP felt that the use of abbreviations in discharge summaries had the potential to impact patient care. A total of 152 (60%) GP felt that time spent clarifying abbreviations in discharge summaries could be excessive.

Abbreviations are often used in discharge summaries, yet poorly understood. This has the potential to impact patient care in the transition period after hospitalisation.