Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping

Abstract

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.Clinicians are accountable for the legibility and accuracy of written patient information. The National Health Service indemnity scheme, the Clinical Negligence Scheme for Trusts 1 bases its premiums on individual Trusts' risk-management and patient-safety systems. One of the standards against which a Trust is assessed is the quality of its health records.In the United Kingdom, the European Working Time Directive 2 is leading to the introduction of full shift systems for junior doctors. Patient information is shared through the use of handover systems and documentation in medical notes. In the paediatric department at The Heart of England NHS Foundation Trust, the team produce a paper handover sheet at every shift change (three times in 24 hours) to transfer information from shift to shift. The written handover sheet is accompanied by a verbal handover. Concerns were raised regarding abbreviation use on these sheets and in the medical notes. An audit was undertaken to investigate the frequency, nature and use of abbreviations in these documents.

Lung sounds: how doctors draw crackles and wheeze

“…Many studies of doctors’ written entries in medical records have been retrospective,2 3 7 8 making between-doctor comparisons difficult because the originating clinical information differs between entries. We controlled the auscultation findings presented to participants in order to compare their drawings in a way not possible with retrospective analyses of different clinical encounters.…”

Medication Safety in Hospitals: Avoiding Medication Errors in the Medication use Process

“…Prescribers use abbreviations for convenience and to save time [81][82][83]. Sheppard et al revealed that 25 handover sheets and 108 medical notes contained over 221 types (2286 abbreviations) and 479 types (3368 abbreviations) of medical abbreviations respectively [84]. Another multicentre study carried out to evaluate the quality of prescription writing showed that abbreviations were used in more than 80% of prescriptions against 30% at one hospital that used electronic prescribing [85].…”

Safe use of symbols in handover documentation for medical teams

“…An audit by the paediatric department at Birmingham Heartlands Hospital (Sheppard et al, 2008) recorded 221 different abbreviations amongst 2286 instances of abbreviation use on 25 handover sheets. Of these, only 14% were recognised by the Trust Intranet Medical Dictionary (TID) and 20% by Mosby's Medical Dictionary (MMD).…”

“…Concern has been reported about the safe use of medical abbreviations in documents such as handover sheets and medical notes, especially when information is being communicated between staff of different specialties (BBC, 2008, Sheppard et al, 2008. This paper describes a study to investigate whether the use of symbols in handover documentation that is shared within and between multidisciplinary teams (MDTs) has similar safety implications.…”