Abbreviations are commonly used in the medical world to save time and space whilst writing in the patients' medical records. As various specialties have evolved, each has developed a collection of commonly used abbreviations within its practice, which may not be recognizable to those not working within the same field. The purpose of this study was to assess whether we, the multidisciplinary team members, correctly interpret the abbreviations used in the medical records. We analysed one week of orthopaedic surgical medical records for the use of abbreviations and assessed their appreciation by other members of the multidisciplinary team by means of a standardized questionnaire. 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 (57.24 per cent) of the abbreviations. There were many misinterpretations of the abbreviations across the specialties posing imminent clinical risk. Whilst abbreviations may indeed save time, the observed inter-group variation in correct interpretation of these abbreviations is unacceptable. We recommend that the abbreviations have no place in the multidisciplinary world and their continued use will only lead to eventual clinical error.

Download full-text PDF

Source
http://dx.doi.org/10.1558/cam.v5i1.25DOI Listing

Publication Analysis

Top Keywords

medical records
16
abbreviations
11
abbreviations medical
8
save time
8
multidisciplinary team
8
correctly interpret
8
records
4
multidisciplinary
4
records multidisciplinary
4
multidisciplinary world--an
4

Similar Publications

Factors associated with higher caregiver burden among informal caregivers of Parkinson's disease: A systematic review.

Medicine (Baltimore)

January 2025

Department of Cardiovascular Medicine, the Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China.

Background: Parkinson's disease is a progressive neurodegenerative disease and the care burden in informal caregivers is huge. Summarizing factors associated with the informal caregivers burden can improve our understanding of providing proactive support to informal caregivers caring for patients with Parkinson's disease (PwP) at risk, and provides evidence for clinical practice.

Methods: PRISMA guidelines were followed in this systematic review.

View Article and Find Full Text PDF

This study assesses the effect of carotid sinus blockade applied with a local anesthetic on hemodynamic parameters during carotid endarterectomy (CEA) operations performed under general anesthesia. The medical records of patients who underwent CEA under general anesthesia between January 2020 and December 2022, were retrospectively reviewed. It was recorded whether the patients received carotid sinus block with 2 mL of 2% prilocaine.

View Article and Find Full Text PDF

Imaging characteristics and treatment of recurrent germinoma.

J Neurosurg

January 2025

1Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima; and.

Objective: An MRI protocol for germinoma surveillance after complete remission has not been established. Moreover, the standard treatment for recurrent or refractory germinoma has not been determined. In this study, the authors explored the imaging characteristics of recurrent germinoma and discuss their institution's experience with multidisciplinary treatment of this malignancy.

View Article and Find Full Text PDF

Consumer Access and Utilization of Patient Portals for Electronic Health Records: A Cross-Sectional Study in Saudi Arabia.

Comput Inform Nurs

January 2025

Author Affiliations: Medical Informatics and E-learning Unit, Medical Education Department, College of Medicine, King Saud University (Dr R.N. Aldekhyyel); College of Medicine, King Saud University (Mss Alshafi, Almohsen, Alhowaish, Alabbad, Alwahibi, and Alsuhaibani); and Department of English Literature, College of Languages, Princess Nourah Bint Abdulrahman University (Dr R. Aldekhyyel), Riyadh, Saudi Arabia; and School of Nursing, University of Minnesota (Dr Rajamani), Minneapolis.

View Article and Find Full Text PDF

Varicella presents a public health challenge in Guatemala, with limited evidence regarding its impact; vaccine is currently absent from the national immunization program. Generating local data on the economic and health burden can support immunization policies. This study describes the use of hospital resources, costs of care, clinical and demographic characteristics, and complications in children with varicella.

View Article and Find Full Text PDF

Want AI Summaries of new PubMed Abstracts delivered to your In-box?

Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!