Mark Chemali1, Emily J Hibbert2, Adrian Sheen3. 1. Nepean Hospital, Sydney, NSW mche3768@uni.sydney.edu.au. 2. Nepean Hospital, Sydney, NSW. 3. Glenmore Park Medical Centre, Sydney, NSW.
Abstract
OBJECTIVES: To determine the incidence of abbreviation use in electronic hospital discharge letters (eDLs) and general practitioner understanding of abbreviations used in eDLsDesign, setting and participants: Retrospective audit of abbreviation use in 200 sequential eDLs was conducted at Nepean Hospital, Sydney, a tertiary referral centre, from 18 December to 31 December 2012. The 15 most commonly used abbreviations and five clinically important abbreviations were identified from the audit. A survey questionnaire using these abbreviations in context was then mailed to 240 GPs in the area covered by the Nepean Blue Mountains Local Health District to determine their understanding of these abbreviations. MAIN OUTCOME MEASURES: Number of abbreviations and frequency of their use in eDLs, and GPs' understanding of abbreviations used in the survey. RESULTS: 321 abbreviations were identified in the eDL audit; 48.6% were used only once. Fifty five per cent of GPs (132) responded to the survey. No individual abbreviation was correctly interpreted by all GPs. Six abbreviations were misinterpreted by more than a quarter of GPs. These were SNT (soft non-tender), TTE (transthoracic echocardiogram), EST (exercise stress test), NKDA (no known drug allergies), CTPA (computed tomography pulmonary angiogram), ORIF (open reduction and internal fixation). These abbreviations were interpreted incorrectly by 47.0% (62), 33.3% (44), 33.3% (44) 32.6% (43), 31.1% (41) and 28.0% (37) of GPs, respectively. CONCLUSION: Abbreviations used in hospital eDLs are not well understood by the GPs who receive them. This has potential to adversely affect patient care in the transition from hospital to community care.
OBJECTIVES: To determine the incidence of abbreviation use in electronic hospital discharge letters (eDLs) and general practitioner understanding of abbreviations used in eDLsDesign, setting and participants: Retrospective audit of abbreviation use in 200 sequential eDLs was conducted at Nepean Hospital, Sydney, a tertiary referral centre, from 18 December to 31 December 2012. The 15 most commonly used abbreviations and five clinically important abbreviations were identified from the audit. A survey questionnaire using these abbreviations in context was then mailed to 240 GPs in the area covered by the Nepean Blue Mountains Local Health District to determine their understanding of these abbreviations. MAIN OUTCOME MEASURES: Number of abbreviations and frequency of their use in eDLs, and GPs' understanding of abbreviations used in the survey. RESULTS: 321 abbreviations were identified in the eDL audit; 48.6% were used only once. Fifty five per cent of GPs (132) responded to the survey. No individual abbreviation was correctly interpreted by all GPs. Six abbreviations were misinterpreted by more than a quarter of GPs. These were SNT (soft non-tender), TTE (transthoracic echocardiogram), EST (exercise stress test), NKDA (no known drug allergies), CTPA (computed tomography pulmonary angiogram), ORIF (open reduction and internal fixation). These abbreviations were interpreted incorrectly by 47.0% (62), 33.3% (44), 33.3% (44) 32.6% (43), 31.1% (41) and 28.0% (37) of GPs, respectively. CONCLUSION: Abbreviations used in hospital eDLs are not well understood by the GPs who receive them. This has potential to adversely affect patient care in the transition from hospital to community care.
Authors: Lisa Grossman Liu; Raymond H Grossman; Elliot G Mitchell; Chunhua Weng; Karthik Natarajan; George Hripcsak; David K Vawdrey Journal: Sci Data Date: 2021-06-02 Impact factor: 6.444