Soto-Arnáez F, Sebastián-Viana T, Carrasco-Garrido P, Fernández-de las Peñas C, Palacios-Ceña D
Hospital Universitario de Fuenlabrada.
An Sist Sanit Navar. 2016 Dec 30;39(3):379-387. doi: 10.23938/ASSN.0234.
Background. The medical record represents the transcript of the pathologic narrative of a patient. Our aims were: to identify the most common abbreviations present in medical records; to identify discouraged abbreviations; to identify polysemic abbreviations; and to show the distribution of the abbreviations according to the type of ward (medical-surgical). Methods. An observational, descriptive and retrospective study by auditing the digital clinical records of patients discharged from FuenlabradaUniversityHospital in 2013 was conducted. Abbreviations in discharge reports and medical order prescriptions present in 78 medical records, corresponding to 39 men and 39 women of different services, were reviewed. Results. All medical records showed abbreviations. The mean of abbreviations in each medical record was 38.9±17.7. Medical records showed 688 different abbreviations, which were repeated up to a total of 3,038 times. The most frequent abbreviations were HTA (n=98; 3.23%), AP (n=89; 2.93%). Twenty-eight abbreviations considered unsafe appeared and were repeated 646 times. The most frequent included SC (n=63; 9.75%), ui (n=49; 7.59%), > (n=38; 5.88%), mcg (n=36; 5.57%). Twenty-three polysemic abbreviations were also identified, the most frequent being H (n=117; 12.81%), MC (n= 109; 11.94%), MP (n=99; 10.84%). Finally, medical wards had 1,866 abbreviations and surgical 1,172 (P <0.001). Conclusions. All medical records revised included unsafe abbreviations. The use of unsafe abbreviations was common among medical services.
背景。病历代表了患者病理情况的记录。我们的目标是：识别病历中最常见的缩写；识别不鼓励使用的缩写；识别多义缩写；并展示缩写在病房类型（内科 - 外科）中的分布情况。方法。通过审核2013年从富恩拉夫拉达大学医院出院患者的数字临床记录进行了一项观察性、描述性和回顾性研究。对78份病历中的出院报告和医嘱处方中的缩写进行了审查，这些病历对应不同科室的39名男性和39名女性。结果。所有病历均显示有缩写。每份病历中缩写的平均数为38.9±17.7。病历中出现了688种不同的缩写，总共重复出现3038次。最常见的缩写是HTA（n = 98；3.23%），AP（n = 89；2.93%）。出现了28种被认为不安全的缩写，共重复646次。最常见的包括SC（n = 63；9.75%），ui（n = 49；7.59%），>（n = 38；5.88%），mcg（n = 36；5.57%）。还识别出23种多义缩写，最常见的是H（n = 117；12.81%），MC（n = 109；11.94%），MP（n = 99；10.84%）。最后，内科病房有1866个缩写，外科病房有1172个缩写（P <0.001）。结论。所有审查的病历都包含不安全缩写。不安全缩写在医疗服务中使用普遍。
