Literature DB >> 19363877

The use of abbreviations in medical records in a multidisciplinary world--an imminent disaster.

Muhammad Asad Parvaiz1, Ashok Subramanian, Namita S Kendall.   

Abstract

Abbreviations are commonly used in the medical world to save time and space whilst writing in the patients' medical records. As various specialties have evolved, each has developed a collection of commonly used abbreviations within its practice, which may not be recognizable to those not working within the same field. The purpose of this study was to assess whether we, the multidisciplinary team members, correctly interpret the abbreviations used in the medical records. We analysed one week of orthopaedic surgical medical records for the use of abbreviations and assessed their appreciation by other members of the multidisciplinary team by means of a standardized questionnaire. We found great variability in the understanding of these abbreviations by different groups of health care professionals. As expected, the orthopaedic surgeons produced significantly more right answers when compared to the other groups, but even they could correctly interpret just over half (57.24 per cent) of the abbreviations. There were many misinterpretations of the abbreviations across the specialties posing imminent clinical risk. Whilst abbreviations may indeed save time, the observed inter-group variation in correct interpretation of these abbreviations is unacceptable. We recommend that the abbreviations have no place in the multidisciplinary world and their continued use will only lead to eventual clinical error.

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Year:  2008        PMID: 19363877     DOI: 10.1558/cam.v5i1.25

Source DB:  PubMed          Journal:  Commun Med        ISSN: 1612-1783


  5 in total

1.  The effectiveness of a 'Do Not Use' list and perceptions of healthcare professionals on error-prone abbreviations.

Authors:  Nithushi R Samaranayake; Dixon S T Cheung; May P S Lam; Tommy T Cheung; William C M Chui; Ian C K Wong; Bernard M Y Cheung
Journal:  Int J Clin Pharm       Date:  2014-08-07

2.  Relevance of the expression "obs stable" in nursing observations: retrospective study.

Authors:  Gregory Scott; Roshan Vijayan; Pandora Male
Journal:  BMJ       Date:  2011-12-20

3.  Consenting operative orthopaedic trauma patients: challenges and solutions.

Authors:  Amin Kheiran; Purnajyoti Banerjee; Philip Stott
Journal:  ISRN Surg       Date:  2014-02-06

4.  Use of abbreviations in consent forms for orthopaedic surgery: A pilot study.

Authors:  M Noah H Khan; Hassan Shafiq; Muhammad Waqas Ilyas; Muhammad Hamzah Jamshed; Ammal Imran Qureshi; Basharat Ghafoor Khan; Neshat Anjum
Journal:  Ann Med Surg (Lond)       Date:  2021-10-15

5.  Poor compliance documenting informed consent in trauma patients with distal radius fractures compared to elective total knee arthroplasty.

Authors:  Scott M Bolam; Leigh Munro; Mark Wright
Journal:  ANZ J Surg       Date:  2022-05-19       Impact factor: 2.025

  5 in total

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