医护人员使用缩写词：未来的路在何方？

Use of abbreviations by healthcare professionals: what is the way forward?

机构信息

Department of Surgery, Torbay Hospital, Torquay TQ2 7AA, UK.

出版信息

Postgrad Med J. 2011 Jul;87(1029):450-2. doi: 10.1136/pgmj.2010.097394. Epub 2011 Apr 1.

DOI:10.1136/pgmj.2010.097394

PMID:21459778

Abstract

OBJECTIVE

To assess the understanding of commonly used abbreviations in the medical records among healthcare professionals.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

摘要

目的

评估医疗保健专业人员对病历中常用缩写的理解。

方法

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。

结果

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。