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缩写:文档记录中对易读性和准确性的要求。

Abbreviations: the need for legibility and accuracy in documentation.

作者信息

Dimond Bridgit

机构信息

University of Glamorgan.

出版信息

Br J Nurs. 2005;14(12):665-6. doi: 10.12968/bjon.2005.14.12.18289.

Abstract

This article explores the use of abbreviations in health care. It considers the current advice of the Nursing and Midwifery Council against the use of any abbreviations and suggests, in the interests of using time effectively, that it would be wise for directorates within trusts to create a list of approved abbreviations and symbols so that the dangers of misunderstandings are removed. It also considers how the problem of illegibility should be dealt with as a clinical governance issue.

摘要

本文探讨了医疗保健中缩写词的使用情况。它考虑了护理及助产士管理局目前反对使用任何缩写词的建议,并出于有效利用时间的考虑,认为信托机构内的各部门制定一份认可的缩写词和符号清单是明智的,这样可以消除误解的风险。它还探讨了应如何将难以辨认的问题作为临床治理问题来处理。

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