Coghlan Anna, Turner Sophie, Coverdale Steven
Sunshine Coast Hospital and Health Service, Sunshine Coast, Queensland, Australia.
Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
Intern Med J. 2023 Apr;53(4):550-558. doi: 10.1111/imj.15582. Epub 2022 Aug 26.
The transition from hospital inpatient care to medical care in the community is a high-risk period for adverse events. Inadequate communication, including low-quality or unavailable discharge summaries, has been shown to impact patient care.
To assess use of abbreviations in clinical handover documents from inpatient hospital teams to general practitioners (GP), and the interpretation of these abbreviations by GP and hospital-based junior doctors.
This is a retrospective audit of 802 discharge summaries completed during a 1-week period in 2017 by a Queensland regional health service. GP and local junior doctors then attempted interpretation of 20 relevant abbreviations.
A total of 99% (794) discharge summaries included abbreviations. A total of 1612 different abbreviations was used on 16 327 occasions. The median number of abbreviations per discharge summary was 17 (range 0-86). A total of 254 GP and 62 junior doctors responded to a survey, which found that no abbreviation was interpreted the same by all respondents. GP and junior doctors were unable to offer any interpretation in 17.9% and 15.2% of cases respectively. GP offered a greater range of interpretations than junior doctors, with a median of 9 and 3 different interpretations per abbreviation respectively. A total of 94% (239) of GP felt that the use of abbreviations in discharge summaries had the potential to impact patient care. A total of 152 (60%) GP felt that time spent clarifying abbreviations in discharge summaries could be excessive.
Abbreviations are often used in discharge summaries, yet poorly understood. This has the potential to impact patient care in the transition period after hospitalisation.
从医院住院治疗过渡到社区医疗是不良事件的高风险期。已表明沟通不足，包括出院小结质量低或无法获取，会影响患者护理。
评估住院医院团队向全科医生（GP）交接临床文件中缩写词的使用情况，以及全科医生和医院初级医生对这些缩写词的解读情况。
这是对昆士兰地区卫生服务机构在2017年1周内完成的802份出院小结的回顾性审计。然后，全科医生和当地初级医生尝试解读20个相关缩写词。
总共99%（794份）出院小结包含缩写词。在16327次使用中，共使用了1612种不同的缩写词。每份出院小结缩写词的中位数为17个（范围0 - 86个）。共有254名全科医生和62名初级医生回复了一项调查，结果发现没有一个缩写词被所有受访者以相同方式解读。全科医生和初级医生分别在17.9%和15.2%的案例中无法给出任何解读。全科医生给出的解读范围比初级医生更广，每个缩写词的不同解读中位数分别为9个和3个。总共94%（239名）全科医生认为出院小结中缩写词的使用有可能影响患者护理。总共152名（60%）全科医生认为在出院小结中澄清缩写词所花费的时间可能过长。
出院小结中经常使用缩写词，但理解不佳。这有可能在住院后的过渡期影响患者护理。
