Viana Alonso A, de la Morena Fernández J
Departamento de Medicina Interna, Hospital Universitario de Guadalajara, Universidad de Alcalá de Henares, Madrid.
An Med Interna. 1998 Apr;15(4):194-6.
Quality of discharge reports is very important for an adequate health care activity. Clinical data of these reports must be comprehensible by patients and in the different levels of Health Services. Presence of abbreviations causes severe shortcomings in the clinical data of these records.
We analyzed the presence of abbreviations in the Internal Medicine discharge reports of 7 hospitals of Castilla-La Mancha in the year 1992. We evaluated 835 discharge reports.
Abbreviations were found in personal background 72.4%, present disease 31%, physical examination 87.2%, clinical judgement 39.4%, complementary explorations 95.8%, evolution 61.4% and treatment-follow up after discharge 67.4%.
These results indicate that abbreviations must be avoided in discharge reports in order to obtain a better communication between patient and doctor and between medical personnel.
