Department of Surgery, Torbay Hospital, Torquay TQ2 7AA, UK.
Postgrad Med J. 2011 Jul;87(1029):450-2. doi: 10.1136/pgmj.2010.097394. Epub 2011 Apr 1.
To assess the understanding of commonly used abbreviations in the medical records among healthcare professionals.
A selection of abbreviations from surgical inpatient admissions (gathered over a 10 day period in October 2008), in the form of a standard questionnaire, was shown to different members of a multidisciplinary team to examine interpretation and knowledge.
209 questionnaires were analysed. The average correct response was 43%. Foundation Year 1 (F1) doctors scored the highest with 57% correct responses, whereas dieticians fared worst (20% correct). Among different abbreviations, NAD (91%) and SCBU (93%) were most often correctly answered, whereas CIC (3%) and STS (0.5%) were the most incorrectly answered. Certain abbreviations which are mostly used by nurses (eg, OTT) achieved a 75% correct response by them compared to only 11% by F1 and 10% by F2 doctors (p<0.001). Similarly, abbreviations such as COBH (p=0.025) and LUTS (p<0.001), although mostly correctly answered by junior doctors, were very poorly answered by nurses.
The majority of healthcare professionals have a very poor knowledge of commonly used abbreviations. Use of unambiguous and approved list of abbreviations is suggested in order to ensure good communication in patient care.
评估医疗保健专业人员对病历中常用缩写的理解。
以标准问卷的形式，向多学科团队的不同成员展示了 2008 年 10 月为期 10 天的外科住院患者中收集的缩写，以检查其解释和知识。
共分析了 209 份问卷。平均正确反应率为 43%。第一年住院医师（F1）得分最高，正确回答率为 57%，而营养师得分最差（20%正确）。在不同的缩写中，NAD（91%）和 SCBU（93%）最常正确回答，而 CIC（3%）和 STS（0.5%）则最不正确。护士常用的某些缩写（例如 OTT），护士的正确回答率为 75%，而 F1 和 F2 医生的正确回答率仅为 11%和 10%（p<0.001）。同样，虽然初级医生大多正确回答了 COBH（p=0.025）和 LUTS（p<0.001）等缩写，但护士的回答却很差。
大多数医疗保健专业人员对常用缩写的了解非常有限。建议使用明确且经批准的缩写列表，以确保在患者护理中进行良好的沟通。
