Interpretation and Misinterpretation of Medical Abbreviations Found in Patient Medical Records: A Cross-Sectional Survey.

Abstract

Introduction Medical abbreviations are used in patient medical records across all departments within the hospital setting and upon discharge. Abbreviations can have more than one contradictory or ambiguous definition, which can resultin errors in communication due to misunderstanding or misinterpretation. Modern patient care is multidisciplinary, sothere should be no room for ambiguity in patient medical records. Therefore, the aim of this survey wasto assessindividual interpretations and misinterpretations of a list of medical abbreviationsfound in patient medical records, and thereby increase awareness of the growing use of non-standard abbreviations. Materials and methods In this cross-sectional survey, anonymized questionnaires containing a list of 20 abbreviations were given to a convenience sample of consultant physicians, doctors-in-training, and nurses, all of whom are involved in the day-to-dayuse of patient medical records. Volunteers were asked to define each abbreviation in full. A provided definition was either the intended definition (given a score of one) or completely different in terms of text and meaning (alternative definition). The intended definitions, alternative definitions, and number of abbreviations that were defined by at least 50% of volunteers were collated. Abbreviations that had more than 50% of volunteers providing the intended definition, were regarded as "generally accepted" abbreviations. Volunteers were assured that this was not a test of knowledge and thatquestionnaires were completely anonymized. Results In total, 46 volunteers completed questionnaires. Volunteers consisted of 15 nurses, 15 doctors-in-training, and 16 consultant physicians. The number of volunteers who provided the intended definition for eachabbreviation ranged from zero to 87%, depending on the abbreviation. Only four out of 20 abbreviations (20%) had more than 50% of volunteers providing the intended definitionand thus regarded as "generally accepted". The maximum score achieved among thevolunteers was 12 out of 20 (60%), and the minimum score achieved was 2 out of 20 (10%). The overallmean score achieved by the volunteers was 6.39 out of 20 (32%). Only one-quarter of the volunteersachieved a score above 50%. Additionally, 75% of the abbreviations had one or more (one to seven)alternative definitions. Conclusions This survey demonstrated that non-standard medical abbreviationsused in patient medical records were being misunderstood or misinterpreted. A majority of abbreviations were not recognized among user groups. Additionally, three-quarters of abbreviationshad one or more alternative definitions. Healthcare institutions should encourage the reporting of errors arising from the usage of abbreviations, and introduce initiatives to discourage the use of non-standard abbreviations in patient medical records.