The shorthand hospital doctors use to describe patients and treatment seems to be as perplexing as their handwriting, an online UK study suggests.
The researchers analysed 25 hand-over sheets and 168 medical records used in the department of paediatrics at one district general hospital, and compared the abbreviations they contained with standard entries in Mosby’s Medical Dictionary, and the Trust Intranet Medial Dictionary.
Paediatric care involved three shift changes within 24 hours, each of which generated a set of hand-over notes.
The notes contained almost 2,300 abbreviations, while almost 3,700 had been used in the medical records.
On average, 91 abbreviations were used in the hand-over sheets, with the number of different abbreviations for the same words amounting to 221.
The medical record average was lower at 21 abbreviations, but there was more scope for using different forms for the same words, with 479 such versions.
Only 14% and 20%, respectively, of the shorthand used in the hand-over notes was found in Mosby’s and the trust dictionaries.
Similarly, only 17% and15%, respectively, of the abbreviations used in the medical notes appeared in the standard dictionaries.
Sometimes different abbreviations were used for the same word. For example, “Normal” would appear as “N,” “NI” and “NAD.”
Some abbreviations also had several possible interpretations, such as “TOF,” which could refer to either tetralogy of Fallot or tracheal-oesophageal fistula.
When the researchers quizzed nine other doctors and healthcare professionals to see how well they understood these shortened forms, they found that many of them were baffled by them.
When presented with a selection of the abbreviations used, doctors recognised 56% to 94% of them, but other healthcare professionals recognised only between 31% and 63%.
Senior house officers used the most abbreviations, followed by registrars, foundation year 1 doctors, staff nurses, and medical students.
But while the paediatric consultant interpreted 94% of the abbreviations correctly, the senior house officer only managed 56%.
One of the standards against which a Trust is assessed for its liability for clinical negligence is the quality, including the clarity, of its health records, say the authors.
And with the rapid approach of full implementation of the European Working Time Directive, shift systems, requiring hand-over notes, will become more common place.
“Whilst abbreviations allow large amounts of information to be conveyed in a small space, this audit demonstrates that most are not recognised by the reference standards” write the authors.
They add that concerns about abbreviations that could be misinterpreted has been raised elsewhere.
But, worryingly, it is impossible to know whether these abbreviations cause serious problems, because so little systematic research has been carried out.
But one US study suggests that at the very least, confusion over the interpretation of abbreviations lengthens hospital stay.
Archives of Disease in Childhood Online First doi: 10.1136/adc.2007.128132