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Postgrad Med J. 2018 Mar 14. pii: postgradmedj-2017-135515. doi: 10.1136/postgradmedj-2017-135515. [Epub ahead of print]

Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record.

Author information

1
Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin, Israel.
2
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
3
Department of Ophthalmology, Edith Wolfson Medical Center, Holon, Israel.
4
Department of Ophthalmology, Soroka University Medical Center, Ben-Gurion University, Beer Sheva, Israel.
5
Department of Ophthalmology, Kaplan Medical Center, Rehovot and the Hebrew University of Jerusalem-Hadassah Medical School, Jerusalem, Israel.

Abstract

AIMS:

Abbreviations are common in the medical record. Their inappropriate use may ultimately lead to patient harm, yet little is known regarding the extent of their use and their comprehension. Our aim was to assess the extent of their use, their comprehension and physicians' attitudes towards them, using ophthalmology consults in a tertiary hospital as a model.

METHODS:

We first mapped the frequency with which English abbreviations were used in the departments' computerised databases. We then used the most frequently used abbreviations as part of a cross-sectional survey designed to assess the attitudes of non-ophthalmologist physicians towards the abbreviations and their comprehension of them. Finally, we tested whether an online lecture would improve comprehension.

RESULTS:

4375 records were screened, and 235 physicians responded to the survey. Only 42.5% knew at least 10% of the abbreviations, and no one knew them all. Ninety-two per cent of respondents admitted to searching online for the meanings of abbreviations, and 59.1% believe abbreviations should be prohibited in medical records. A short online lecture improved the number of respondents answering correctly at least 50% of the time from 1.2% to 42% (P<0.001).

CONCLUSIONS:

Abbreviations are common in medical records and are frequently misinterpreted. Online teaching is a valuable tool for physician education. The majority of respondents believed that misinterpreting abbreviations could negatively impact patient care, and that the use of abbreviations should be prohibited in medical records. Due to low rates of comprehension and negative attitudes towards abbreviations in medical communications, we believe their use should be discouraged.

KEYWORDS:

medical abbreviations; medical education; medical errors; ophthalmology

Conflict of interest statement

Competing interests: None declared.

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