The use of abbreviations in medical records in a multidisciplinary world -- an imminent disaster

Authors

  • Muhammad Asad Parvaiz New Cross Hospital, Wolverhampton
  • Ashok Subramanian
  • Namita S. Kendall Consultant in Trauma and Orthopaedics, Chicester

DOI:

https://doi.org/10.1558/cam.v5i1.25

Keywords:

orthopaedics, abbreviations, multidisciplinary teams, , medical records, misinterpretation

Abstract

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.

Author Biographies

Muhammad Asad Parvaiz, New Cross Hospital, Wolverhampton

Muhammad Asad Parvaiz has a B.Sc. in English Language, MBBS and MRCS. He is a gold medallist in Human Physiology and is currently a registrar in general surgery in New Cross Hospital Wolverhampton, UK. His main interest is the assessment of communication in medical records and he presented this article at the 4th Interdisciplinary COMET Conference; Communication, Medicine & Ethics at Cardiff University 29 June–1 July 2006.

Ashok Subramanian

Ashok Subramanian has a B.Sc. with honours, MBBS and MRCS and is currently a specialist surgical registrar. He has a special interest in teaching methods and communication skills between medical and surgical disciplines.

Namita S. Kendall, Consultant in Trauma and Orthopaedics, Chicester

Namita S. Kendall is a consultant in Trauma & Orthopaedic in Chichester. She is a fellow of Royal College of Surgeons of Edinburgh and has an interest in education and teaching programmes for junior doctors.

Published

2008-11-27

How to Cite

Parvaiz, M. A., Subramanian, A., & Kendall, N. S. (2008). The use of abbreviations in medical records in a multidisciplinary world -- an imminent disaster. Communication and Medicine, 5(1), 25–34. https://doi.org/10.1558/cam.v5i1.25

Issue

Section

Articles