Medical abbreviations: writing little and communicating less

Abstract

The article by Sheppard and colleagues1 in the March issue of Archives of Diseases in Childhood describes the overuse of ambiguous abbreviations in paediatric note taking. Reading this article led one of us to review a clinic note written earlier in the day describing a “2 yo F here for a RPE w/a recent URI who c/o ear pain y/d”. On further inspection, this note was found to contain 35 abbreviations, all of which were completely unambiguous to the author when the note was written. However, many could certainly cause confusion should any other healthcare providers require information to make clinical decisions about this patient in the future. Optimal communication between healthcare providers, frequently through our notes, is essential for supplying high quality care within and across clinical settings. With the involvement of greater numbers of healthcare professionals in the care of patients, and with provider responsibilities often restricted to either the hospital or ambulatory settings, substantial attention is being focused on improving handovers and transitions in medical care. Sheppard and colleagues1 have systematically detailed one important challenge to communicating written information about our patients, with serious implications. They describe the prolific use of ambiguous medical abbreviations in note keeping. In their review of 25 paediatric handover sheets and 168 sets of medical notes, the authors identified 221 and 3668 abbreviations, respectively. Paediatric physicians were able to accurately recognise 56–94% of these. However, only about half of the abbreviations were understood by other healthcare professionals, such as ancillary staff or physicians from other disciplines. While …

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