Department of Pediatrics, Assaf Harofeh Medical Center, Zerifin, Israel.
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Postgrad Med J. 2018 May;94(1111):254-258. doi: 10.1136/postgradmedj-2017-135515. Epub 2018 Mar 14.
Abbreviations are common in the medical record. Their inappropriate use may ultimately lead to patient harm, yet little is known regarding the extent of their use and their comprehension. Our aim was to assess the extent of their use, their comprehension and physicians' attitudes towards them, using ophthalmology consults in a tertiary hospital as a model.
We first mapped the frequency with which English abbreviations were used in the departments' computerised databases. We then used the most frequently used abbreviations as part of a cross-sectional survey designed to assess the attitudes of non-ophthalmologist physicians towards the abbreviations and their comprehension of them. Finally, we tested whether an online lecture would improve comprehension.
4375 records were screened, and 235 physicians responded to the survey. Only 42.5% knew at least 10% of the abbreviations, and no one knew them all. Ninety-two per cent of respondents admitted to searching online for the meanings of abbreviations, and 59.1% believe abbreviations should be prohibited in medical records. A short online lecture improved the number of respondents answering correctly at least 50% of the time from 1.2% to 42% (P<0.001).
Abbreviations are common in medical records and are frequently misinterpreted. Online teaching is a valuable tool for physician education. The majority of respondents believed that misinterpreting abbreviations could negatively impact patient care, and that the use of abbreviations should be prohibited in medical records. Due to low rates of comprehension and negative attitudes towards abbreviations in medical communications, we believe their use should be discouraged.
缩略语在病历中很常见。它们的不当使用最终可能导致患者受到伤害，但对于它们的使用程度及其理解程度，人们知之甚少。我们的目的是评估其使用程度、理解程度以及医生对它们的态度，以一家三级医院的眼科咨询为模型。
首先，我们在科室的计算机数据库中统计了英文缩写的使用频率。然后，我们使用最常使用的缩写作为横断面调查的一部分，旨在评估非眼科医生对缩写的态度及其对缩写的理解程度。最后，我们测试了在线讲座是否可以提高理解能力。
共筛选了 4375 份记录，有 235 名医生对调查做出了回应。只有 42.5%的人至少知道 10%的缩写，没有人知道所有的缩写。92%的受访者承认他们会在网上搜索缩写的含义，而 59.1%的人认为缩写应该禁止出现在病历中。一个简短的在线讲座将至少答对 50%的题目的回答者比例从 1.2%提高到 42%（P<0.001）。
缩略语在病历中很常见，并且经常被误解。在线教学是医生教育的一种有价值的工具。大多数受访者认为误解缩写可能会对患者护理产生负面影响，并且缩写应该禁止出现在病历中。由于缩略语在医疗交流中的理解程度和负面态度较低，我们认为应该不鼓励使用它们。
