Why use abbreviations in medical records

Effective communication between patient care team members is essential, and abbreviations can obfuscate what should be simple medical recommendations. A similar study looked at a selection of abbreviations from recent hospital admissions and asked different members of a multidisciplinary care team to decipher them. A recent study of three hospitals in Australia looked at lists of error-prone abbreviations in prescriptions from the National Coordinating Council for Medication Error Reporting and Prevention, the Institute for Safe Medications Practices, and the Joint Commission, and compared them to the abbreviations used in their hospitals.

Of the medication orders they studied, error-prone abbreviations were found, with an average of 2. With such widespread use of error-prone abbreviations and known morbidity as demonstrated by the MEDMARX program, there have been efforts at rectifying the problem.

In , The Joint Commission on Accreditation of Healthcare Organizations approved a National Patient Safety Goal requiring accredited organizations to implement a list of abbreviations not to use. However, this requirement does not apply to preprogrammed health information technology, and abbreviations remain common in electronic medical records.

Advancements in electronic medical records, including electronic prescription use, can help, but free-text to describe medications and typed patient histories are not affected by these systems. To rectify these problems, a study done in an emergency room at a tertiary care center developed an unapproved abbreviations list and, using a computerized tool to detect the unapproved abbreviations, provided doctors with individual feedback at the end of each month on their abbreviation use with comparisons to peers.

The impact of abbreviations on patient safety. The vocabulary of technical terms used in a particular field, subject, science, or art; nomenclature. An abbreviation, simply put, is a shortened form of a word. In writing, abbreviations are useful when you need to squeeze a lot of writing into a small space. You can also use them in place of long or cumbersome phrases to make your sentences easier to read.

The combining form is important because we need to know where the connection comes into view. For example, the combining vowel serves no purpose except to connect one root to another root as well as roots to suffixes. Last Updated: 17 days ago — Co-authors : 13 — Users : Save my name, email, and website in this browser for the next time I comment. Notify me of follow-up comments by email.

Notify me of new posts by email. Home Answers About. Sign in. Forgot your password? Get help. Password recovery. Home English Why do healthcare professionals use abbreviations? English General Lifestyle. Read the full answer Medical Care Evaluation Studies Beside this, Why is it important for health professionals to use medical terminology? Also Read Is premier or grand cru better? Share this: Twitter Facebook. Is Whataburger only in Texas? Is the nacho party pack worth it? Please enter your answer!

Please enter your name here. We found great variability in the understanding of these abbreviations by different groups of health care professionals. As expected, the orthopaedic surgeons produced significantly more right answers when compared to the other groups, but even they could correctly interpret just over half There were many misinterpretations of the abbreviations across the specialties posing imminent clinical risk.