Do multidisciplinary team members correctly interpret the abbreviations used in the medical records?

Abstract

Background and Aims Abbreviations are commonly used in the medical world to save time and space whilst writing in the patients’ case notes. As various specialties have evolved, each has developed a collection of commonly used abbreviations within its practice, which may not be easily recognisable to those working as an allied branch. The purpose of this study was to assess whether we, the multidisciplinary team members, interpret the abbreviations used in the medical records correctly? Methods and Results We analysed orthopaedic inpatient admission case notes (n = 45) for the use of abbreviations (n = 57) and their appreciation by different members of the multidisciplinary team (n = 175) by means of a standardised questionnaire. We found a wide variation in understanding and interpretation of orthopaedic abbreviations among health care professionals. Even the orthopaedic surgeons could answer correctly 57.2% only, followed by physiotherapists (49.9%). Non-orthopaedic groups produced significantly less number of correct answers than the orthopaedic surgeons (p <0.019). Interestingly, nursing and physiotherapy departments produced significantly fewer mal-interpretations than the orthopaedic surgeons (p <0.023). Conclusions Whilst abbreviations may indeed save time, the use of confusing abbreviations is unacceptable. We recommend that acronym obsession should be discouraged in order to reduce possible clinical error.