| Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. | |
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MedLine Citation:
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PMID: 19154556 Owner: NLM Status: In-Data-Review |
Abstract/OtherAbstract:
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Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. SheppardJ. E., WeidnerL. C. E., ZakaiS., Fountain-PolleyS. & WilliamsJ. (2008) Archives of Disease in Childhood, 93, 204-206. DOI: 10.1136/adc.2007.128132. Objective To assess the frequency, nature and understanding of abbreviations in medical records. Design Audit of abbreviation use and meaning in paediatric handover sheets and medical notes compared with two standards, the Trust Intranet Medical Dictionary (TID) and Mosby's Medical Dictionary (MMD). A selection of abbreviations was shown to healthcare professionals to examine interpretation of abbreviations. Setting Large inner-city district general hospital, Birmingham, UK. Main outcome measures Frequency, nature and understanding of abbreviations in paediatric medical records. Results On 25 handover sheets, a total of 2286 abbreviations were used, with 221 different abbreviations; the standards recognized 14% (TID) and 20% (MMD) of these abbreviations. In 168 sets of medical notes, a total of 3668 abbreviations were used, with 479 different abbreviations; the standards recognized 15% (TID) and 17% (MMD). Some words were shortened in different forms; for example, normal (N, Nl, NAD) and some abbreviations had multiple interpretations that differed from those intended, for example, TOF (tetralogy of Fallot, tracheo-oesophageal fistula). When presented with a selection of abbreviations, paediatric doctors recognized 56-94% and other healthcare professionals recognized 31-63%. Conclusion Abbreviation use was widespread in paediatric note keeping. There was no systematic approach to this and difficulties in interpretation were demonstrated. The use of standardized abbreviations to avoid confusion is suggested. |
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Authors:
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Richard Reading |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Child: care, health and development Volume: 34 ISSN: 1365-2214 ISO Abbreviation: - Publication Date: 2008 Jul |
Date Detail:
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Created Date: 2009-01-21 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 7602632 Medline TA: Child Care Health Dev Country: England |
Other Details:
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Languages: eng Pagination: 545-6 Citation Subset: IM |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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