Analysis of abbreviations used by residents in admission notes and discharge summaries

Analysis of abbreviations used by residents in admission notes and discharge summaries Abstract Background There are abbreviations that are used daily such as BP for blood pressure and ECG for electrocardiogram, but many of the abbreviations found in medical documents are unclear. Aim The purpose of this study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents. Methods Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The frequency of use of the abbreviations was determined. Additionally, the fifty commonest abbreviations from each specialty were graded by three medical and three orthopedic surgery senior physicians as 1. understandable or 2. Ambiguous or unknown. Results The number of abbreviations found in the documents composed by medical and orthopedic surgery residents was 1525 with 80 different abbreviations and 493 with 51 different abbreviations respectively (9.3% and 4.9% of the total word number respectively). Analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians. Conclusion In order to prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non standard abbreviations such as the incorporation of authorized abbreviations to the electronic medical record. Introduction The Joint Commission’s Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the cause of over half the serious adverse events in accredited hospitals. Extensive use of abbreviations is a common cause of difficulties in understanding medical documents such as admission notes, discharge letters and correspondence between primary care physicians and specialists. Oxford online dictionary defines abbreviation as any shortened form of a word or phrase.1 The term abbreviation includes abbreviations such as electrocardiogram (ECG), acronyms which are defined as an abbreviations formed from the initial letters of other words and pronounced as a word such as acquired immune deficiency syndrome (AIDS), contractures such as Staph. Aureus and initialism: an abbreviation consisting of initial letters pronounced separately, for example FDA. In medical writing as opposed to other types of genres there is extensive use of abbreviations, and the number of abbreviations is growing with the addition of sub-specialties, each creates new set of abbreviations. The reason for the extensive use of abbreviations may be the desire to save space and time and the common occurrence of long and complex terms in the medical jargon.2,3 Abbreviations used in research manuscripts are usually accompanied by the full phrase, at least in their first appearance.3 In contrast, clinical note writing such as admission notes, discharge letters and consultations, do not include description of the abbreviations. Written communication between physicians such as referral letters and consultations may be especially problematic, since these documents are usually sent to physicians from different disciplines, but this was not studied. Physicians from each specialty may use different sets of abbreviations and thus the documents may be difficult to comprehend by physicians and other members of the multi-disciplinary team from other specialties and thus compromise patient care.2 Despite the fact that the use of abbreviations is common in clinical writing, frequently they are ambiguous or misunderstood. In addition, abbreviations may have several interpretations, for example, the common abbreviation DM can be shorthand for diabetes mellitus type 1, type 2, dermatomyositis, degenerative myelopathy and diastolic murmur. The abbreviation MVR can be interpreted as mitral valve regurgitation, or mitral valve repair, or mitral valve replacement. Literature search on the use of abbreviations in admission notes and discharge letters revealed only few manuscripts which dealt mostly with disambiguation to the purpose of using them in coding systems and medical informatics.4–6 In a manuscript published by Politis et al. that examined shorthand in discharge letter from medical wards, the authors found that approximately 20% of the words were abbreviations and of this 6.8% were inappropriate, ambiguous or unknown.3 Sheppard and her colleagues examined the abbreviation use in pediatrics, and found 221 different abbreviations in 25 handover pages and 479 different abbreviations in medical notes.7 Less than 40% were recognized by the standards they used, the medical dictionary available on the hospital intranet and Mosby’s medical dictionary.8,9 Chemali et al. conducted an audit of abbreviations found in discharge summaries and found that 6 abbreviations were interpreted incorrectly by more than 25% of the general practitioners answering their questionnaire.10 Sinha et al. studied the interpretation of abbreviations from surgery and found that only 43% were interpreted correctly.2 The authors of these articles suggested several possible ways which can be used to deal with this issue, including approved shorthand lists and addressing the issue during intern orientation. Despite extensive literature search, we could not find manuscripts regarding other ways that can be used to prevent the use of unauthorized abbreviations. Suggestions intended to decrease unauthorized abbreviation such as ‘do not use’ lists probably did not have significant effect since physician continue to abbreviate terms frequently as reflected by recent article on the subject.11 In the current study, we examined the frequency of use and the comprehension of abbreviations from admission notes and discharge letters composed by medical and orthopedic surgery residents. The purpose of examining this subject in two specialties was to find out whether and to what extent clinicians from one specialty are familiar with abbreviations used by clinicians from another specialty, a subject that to the best of our knowledge was not studied before. Materials and methods The study included 80 admission notes and discharge letters composed by 44 residents from 3 medical wards and 2 orthopedic surgery wards (20 admission notes and 20 discharge summaries from each specialty). The admission notes and discharge letters were randomly sampled from documents written from June 2016 to July 2016 and all identifying details were removed from the documents. Although collecting the discharge letters and admission notes, we verified that no more than two documents were written by the same resident. We recorded the abbreviations included in every document from the two specialties. Following data collection, the number of different abbreviations and the number of times each abbreviation appeared in the documents from each specialty were calculated. The first sentence containing each abbreviation was used for analysis by three senior physicians and three senior orthopedic surgeons. All clinicians were board certified at least 5 years prior to the study. The senior clinicians graded the abbreviations as common and understandable or ambiguous and unknown. In the cases, where the senior clinicians graded the abbreviation differently, the disagreement was resolved by discussion. The following abbreviations were excluded: (A) the titles Dr. and Prof. were not included since they appear automatically on the heading of every document produced from the electronic patient record. (B) Abbreviations of laboratory test names were omitted since they are part of the table of tests included automatically in the electronic document. (C) Abbreviation of measurements such as mg, mcg and kg were not included since they are standard unit of measure, and their use is allowed even in research manuscripts.9,12 As the documents composed by medical residents were significantly longer, the percentage and not the number of abbreviations is presented in order to compensate for the difference in length. Statistical analysis; in order to examine the association between document type, ward and document characteristics, a mixed repeated measures ANOVA was applied with document type (admission or discharge) serving as the independent variable and ward (medical or orthopedic) serving as the dependent variable. Total number of words in the documents and the percentage of abbreviations served as dependent variables (a separate model for each dependent variable). Associations between frequency data were examined using Pearson’s chi-square test. All analyses were two-tailed and a P-values ≤ 0.05 was considered significant. All analyses were performed using IBM-SPSS21. The study was approved by the Meir Hospital Institutional Ethics Committee. Results The total number of abbreviations found in the 40 admission notes and discharge summaries written by medical residents was 1525 with 80 different abbreviations. The number of abbreviations in the documents written by the orthopedic surgery residents was 493 with 51 different abbreviations. As can be observed in Table 1, the admission notes and discharge letters composed by the medical residents were longer than those prepared by the orthopedic surgery residents (P < 0.001 and P < 0.02, respectively). Table 1 Comparison between admission notes and discharge letters from medical and orthopedic surgery wards Variable  Medical ward  Orthopedic ward  P value  M ± SD  M ± SD  Total number of words   Admission  457 ± 170  187 ± 63  P < 0.001   Discharge  538 ± 193  249 ± 97  P < 0.02  Percentage of abbreviations   Admission  9.3 ± 4.5  6.3 ± 3.4  P = 0.004   Discharge  6.8 ± 1.8  4.9 ± 2.4  P = 0.005  Variable  Medical ward  Orthopedic ward  P value  M ± SD  M ± SD  Total number of words   Admission  457 ± 170  187 ± 63  P < 0.001   Discharge  538 ± 193  249 ± 97  P < 0.02  Percentage of abbreviations   Admission  9.3 ± 4.5  6.3 ± 3.4  P = 0.004   Discharge  6.8 ± 1.8  4.9 ± 2.4  P = 0.005  Abbreviations: M, Mean; SD, Standard deviation. The percentage of abbreviations in admission notes and discharge letters was significantly smaller in the orthopedic surgery compared to the medical group documents (P < 0.005). It is interesting that the percentage of abbreviations was smaller in the discharge letters than in the admission notes (P < 0.01). This may suggest that since discharge letters are read by physicians outside the ward and by patients the residents tried to write them in more ‘formal’ language. The second aim of the study was to compare the comprehension of abbreviated terms. As described in the Materials and Methods Section, the medical and orthopedic surgery senior clinicians graded each abbreviated term from both groups as understandable or unknown. Analysis of the lists of abbreviations revealed that 14% of the abbreviations from the medical ward documents were graded as unknown by the medical ward senior physicians compared to 25% by the senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups the senior orthopedic surgeons graded 8% as unknown compared to 21% by the medical ward senior physicians. These differences were statistically significant. Table 2 lists the 10 most common abbreviations which were graded as understandable by senior clinicians from the same specialty. Examination of Table 2 reveals that some of the abbreviations are used by both groups of residents, although they did not use them in the same frequency. Examples for such abbreviations are status post (S/P), computed tomography (CT) and hypertension (HTN). Other abbreviations were used only by one discipline such as chest radiogram (CXR) by the medical residents and spine (SPN) by the orthopedic surgery residents. The abbreviated term neurovascular (NV) merits further discussion since it belongs to a group of ‘niche’ abbreviations. Table 2 Ten most common understandable abbreviations used by medical and orthopedic surgery residents as graded by senior physicians from the same specialty Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  S/P (status post)  27  S/P (status post)  36  ECG (electrocardiogram)  24  NV (neurovascular)  25  HTN (hypertension)  24  CT (computed tomography)  16  BIL (bilateral)  23  LT (left)  12  BIL (bilateral)  18  HTN (hypertension)  9  CT (computed t omography)  12  BIL (bilateral)  9  DVT (deep vein T hrombosis)  12  SPN (spine)  8  CXR (chest radiogram)  12  USU (usually)  7  CVA (cerebrovascular a ccident)  12  TKR (total knee replacement)  6  CHF (congestive heart failure)  9  ORIF (open reduction internal fixation)  4  Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  S/P (status post)  27  S/P (status post)  36  ECG (electrocardiogram)  24  NV (neurovascular)  25  HTN (hypertension)  24  CT (computed tomography)  16  BIL (bilateral)  23  LT (left)  12  BIL (bilateral)  18  HTN (hypertension)  9  CT (computed t omography)  12  BIL (bilateral)  9  DVT (deep vein T hrombosis)  12  SPN (spine)  8  CXR (chest radiogram)  12  USU (usually)  7  CVA (cerebrovascular a ccident)  12  TKR (total knee replacement)  6  CHF (congestive heart failure)  9  ORIF (open reduction internal fixation)  4  Table 3 includes the five most common ambiguous or unknown abbreviations. The table includes the abbreviations used by both medical and orthopedic surgery residents, as graded by senior clinicians from the same specialty. Some abbreviations, for example, chronic atrial fibrillation (CAF) which was recognized by all medical senior physicians was categorized as unknown ambiguous by the senior orthopedic surgeons. Table 3 Five most common ambiguous or unknown abbreviations used by medical residents and by orthopedic surgery residents and graded by senior physician from the same specialty Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  HRF (Heart failure)  6  PROB (Probably)  4  W (Widow)  4  LE (Lesion)  3  HSM (Hepatosplenomegally)  4  CAF (Chronic atrial fibrillation  3  LTR (Later)  3  LIII (Third lumbar vertebra)  2  PUL (Pulmonary)  3  BX (Antibiotic)  2  Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  HRF (Heart failure)  6  PROB (Probably)  4  W (Widow)  4  LE (Lesion)  3  HSM (Hepatosplenomegally)  4  CAF (Chronic atrial fibrillation  3  LTR (Later)  3  LIII (Third lumbar vertebra)  2  PUL (Pulmonary)  3  BX (Antibiotic)  2  Table 4 includes the grading of the senior clinicians of abbreviations from both groups of the documents composed by medical and orthopedic surgery residents. When graded by medical senior physicians the percent of unknown or ambiguous abbreviations in the documents composed by orthopedic surgery residents increased from 8% to 21%. The opposite was found when senior orthopedic surgeons graded the documents composed by the medical residents, the percent of ambiguous or unknown abbreviations increased from 14% to 21%. Table 4 Percentage of abbreviations judged as ambiguous by medical or orthopedic surgery senior physicians Department  Percentage of unknown abbreviations in medical documents (%)  Percentage of unknown abbreviations in orthopedic surgery documents (%)  Senior medical physicians  *8  *21  Senior orthopedic surgery physicians  **21  **14  Department  Percentage of unknown abbreviations in medical documents (%)  Percentage of unknown abbreviations in orthopedic surgery documents (%)  Senior medical physicians  *8  *21  Senior orthopedic surgery physicians  **21  **14  * P < 0.001. ** P < 0.005. Discussion Abbreviations are stylistic markers of the medical jargon. We found that 4.9–9.3% of the words in admission notes and discharge letters were abbreviations. Interestingly, the medical residents used significantly more abbreviated terms than the orthopedic surgery residents. The reason for this difference may be partly explained by short or even lack of the medical history section in documents written by the orthopedic surgery residents. The percentage of abbreviations was smaller in discharge letters in both groups. When comparing admission notes to discharge letters, we found that the Discussion Section was longer and contained fewer abbreviations since part of the abbreviations included in the admission notes were omitted or replaced by the exact terms. This may indicate that the residents attempted to replace some of the abbreviations with the exact term in these documents for clarification. The percentage of abbreviations found in the discharge letters was smaller than that found in other studies. This may be partly explained by the omission of measurement units, titles and laboratory test names.9,12 Additionally, in the EMR system used in the hospital medication names cannot be abbreviated since when typing the first letters of a drug a list of medications that is comprised of the generic name and type of preparation appears and the user must choose one of them. This system eliminates the use of drug name abbreviations and may decrease the number of errors during drug prescription. The second part of the study included investigating the comprehension of abbreviations by senior clinicians from medical and orthopedic surgery departments. We found that each group understood the meaning of more abbreviations from the same discipline than from the other discipline. This finding is worrisome, since it indicates that clinicians from one discipline may have difficulty in understanding documents written by clinicians from another specialty, and thus may compromise optimal patient care. Abbreviations such as MRI may be universally accepted. On the other hand, we found that the abbreviation NV was the second most common abbreviation in orthopedic surgery but was not understood by the medical senior physicians. The orthopedic surgery residents use NV in the physical examination part of the documents as ‘NV normal.’ When examining documents from other institutions we could not find this abbreviated term. This demonstrates a common phenomenon of abbreviations that exists only in one ward or institution and not in another (‘niche’ abbreviations). Additionally, an abbreviation may have several meanings, for example; RA may be interpreted as rheumatoid arthritis, room air, right atrium or right arm. On the other hand, several abbreviations may exist for one term, for example: chronic renal failure may be abbreviated as CRF, CKD and RF. Using abbreviations with several meanings and multiple abbreviations for the same term may also cause misunderstanding of medical documents. Several suggestions were found in the literature regarding proper use of ‘standard abbreviations,’ Sheppard and her colleagues suggested using a list of standard abbreviations based on Mosby’s Medical Dictionary displayed in the department.7 Others have also suggested use of easily accessed lists of abbreviations and reinforcing the proper use of shorthand early in training. As studies from recent years show that the number and type of abbreviations does not decrease, it seems that the suggestions of ways intended to decrease the use of abbreviations that are not understandable or have several meanings did not decrease the use of this abbreviations.11 As impaired patient care and medico legal issues may evolve from the inappropriate use of shorthand, a pragmatic way of resolving the issue may be an administrative decision by the organization or institution to allow the use of authorized abbreviations only. We suggest that a list of approved abbreviations that is composed mostly of terms used in spoken medical language such as CT scan, MRI and AIDS and does not have several meanings should be prepared. These abbreviations list should be incorporated into the EMR as are generic names of drugs and an abbreviation must be chosen from the list, otherwise the writer will not be able use them while typing as is the case with medication names during the prescribing process. Additionally, the awareness of the potential damage to patients and the medico legal implications of widespread shorthand uses among should be emphasized to senior physicians and tutors that teach medical students and residents. The senior physicians and tutors of medical students will be asked to explain why the avoidance of abbreviations which are not universally acceptable and included in the lists of allowed abbreviations is important. As the ability to compose clear and concise documents is critical, we suggest that a course in medical document composition should be included as part of the curriculum in medical schools, as was suggested for learning how to prepare detailed list of problems in the wards for the next shift.13 Conclusion The aim of the study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents. Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The 50 most common abbreviations were graded by 3 medical and 3 orthopedic surgery senior clinicians as: (1) understandable and (2) ambiguous or unknown. Our findings indicate that abbreviation use is common and their frequency was 9.3 and 4.9% of the total word count in documents composed by medical and orthopedic surgery residents. Additionally, analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians. Our suggestion is that in order to improve comprehension of medical documents and prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non-standard abbreviations such as education beginning in medical school and the incorporation of authorized abbreviations to the electronic medical record. Compliance with ethical standards This study was not funded by any entity. Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors and it was approved by Meir Hospital Ethics Committee. Conflict of interest: None declared. References 1 Oxford Online Dictionary. 2007. http://www.oxforddictionaries.com/us/definition/american_english/ (25 June 2017, date last accessed). 2 Sinha S, McDermott F, Srinivas G, Houghton PW. Use of abbreviations by healthcare professionals: what is the way forward? Postgrad Med J  2011; 87: 450– 2. Google Scholar CrossRef Search ADS PubMed  3 Politis J, Lau S, Yeoh J, Brand C, Russell D, Liew D. Overview of shorthand medical glossary (OMG) study. Intern Med J  2015; 45: 423– 7. Google Scholar CrossRef Search ADS PubMed  4 Leaman R, Khare R, Lu Z. Challenges in clinical natural language processing for automated disorder normalization. J Biomed Inform  2015; 57: 28– 37. http://dx.doi.org/10.1016/j.jbi.2015.07.010 Google Scholar CrossRef Search ADS PubMed  5 Spasic I, Livsey J, Keane JA, Nenadic G. Text mining of cancer-related information: review of current status and future directions. Int J Med Inform  2014; 83: 605– 23. http://dx.doi.org/10.1016/j.ijmedinf.2014.06.009 Google Scholar CrossRef Search ADS PubMed  6 Xu H, Wu Y, Elhadad N, Stetson PD, Friedman C. A new clustering method for detecting rare senses of abbreviations in clinical notes. J Biomed Inform  2012; 45: 1075– 83. http://dx.doi.org/10.1016/j.jbi.2012.06.003 Google Scholar CrossRef Search ADS PubMed  7 Sheppard JE, Weidner LC, Zakai S, Fountain-Polley S, Williams J. Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. Arch Dis Child  2008; 93: 204– 6. Google Scholar CrossRef Search ADS PubMed  8 Online Medical Dictionary via Trust Intranet. Department of Medical Oncology, University of Newcastle Upon Tyne; http://cancerweb.nci.ac.uk/omd/ (10 June 2017, date last accessed). 9 Anderson DM. Mosby’s Medical, Nursing, and Allied Health Dictionary , 9th edn. Mosby, St. Louis, 2012. 10 Chemali M, Hibbert EJ, Sheen A. General practitioner understanding of abbreviations used in hospital discharge letters. Med J Aust  2015; 203: 147, 147e.1-4. Google Scholar CrossRef Search ADS PubMed  11 Awan S, Abid S, Tariq M, Zubairi ABS, Kamal A, Arshad S, et al.   Use of medical abbreviations and acronyms: knowledge among medical students and postgraduates. Postgrad Med J  2016; 92: 721– 5. Google Scholar CrossRef Search ADS PubMed  12 Instruction for Authors. Spine. http://www.editorialmanager.com/spine/default.aspx (10 June 2017, date last accessed). 13 Chu ES, Reid M, Burden M, Mancini D, Schulz T, Keniston A, et al.   Effectiveness of a course designed to teach handoffs to medical students. J Hospital Med  2010; 5: 344– 8. Google Scholar CrossRef Search ADS   © The Author(s) 2017. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png QJM: An International Journal of Medicine Oxford University Press

Analysis of abbreviations used by residents in admission notes and discharge summaries

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Abstract

Abstract Background There are abbreviations that are used daily such as BP for blood pressure and ECG for electrocardiogram, but many of the abbreviations found in medical documents are unclear. Aim The purpose of this study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents. Methods Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The frequency of use of the abbreviations was determined. Additionally, the fifty commonest abbreviations from each specialty were graded by three medical and three orthopedic surgery senior physicians as 1. understandable or 2. Ambiguous or unknown. Results The number of abbreviations found in the documents composed by medical and orthopedic surgery residents was 1525 with 80 different abbreviations and 493 with 51 different abbreviations respectively (9.3% and 4.9% of the total word number respectively). Analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians. Conclusion In order to prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non standard abbreviations such as the incorporation of authorized abbreviations to the electronic medical record. Introduction The Joint Commission’s Annual Report on Quality and Safety 2007 found that inadequate communication between healthcare providers, or between providers and the patient and family members, was the cause of over half the serious adverse events in accredited hospitals. Extensive use of abbreviations is a common cause of difficulties in understanding medical documents such as admission notes, discharge letters and correspondence between primary care physicians and specialists. Oxford online dictionary defines abbreviation as any shortened form of a word or phrase.1 The term abbreviation includes abbreviations such as electrocardiogram (ECG), acronyms which are defined as an abbreviations formed from the initial letters of other words and pronounced as a word such as acquired immune deficiency syndrome (AIDS), contractures such as Staph. Aureus and initialism: an abbreviation consisting of initial letters pronounced separately, for example FDA. In medical writing as opposed to other types of genres there is extensive use of abbreviations, and the number of abbreviations is growing with the addition of sub-specialties, each creates new set of abbreviations. The reason for the extensive use of abbreviations may be the desire to save space and time and the common occurrence of long and complex terms in the medical jargon.2,3 Abbreviations used in research manuscripts are usually accompanied by the full phrase, at least in their first appearance.3 In contrast, clinical note writing such as admission notes, discharge letters and consultations, do not include description of the abbreviations. Written communication between physicians such as referral letters and consultations may be especially problematic, since these documents are usually sent to physicians from different disciplines, but this was not studied. Physicians from each specialty may use different sets of abbreviations and thus the documents may be difficult to comprehend by physicians and other members of the multi-disciplinary team from other specialties and thus compromise patient care.2 Despite the fact that the use of abbreviations is common in clinical writing, frequently they are ambiguous or misunderstood. In addition, abbreviations may have several interpretations, for example, the common abbreviation DM can be shorthand for diabetes mellitus type 1, type 2, dermatomyositis, degenerative myelopathy and diastolic murmur. The abbreviation MVR can be interpreted as mitral valve regurgitation, or mitral valve repair, or mitral valve replacement. Literature search on the use of abbreviations in admission notes and discharge letters revealed only few manuscripts which dealt mostly with disambiguation to the purpose of using them in coding systems and medical informatics.4–6 In a manuscript published by Politis et al. that examined shorthand in discharge letter from medical wards, the authors found that approximately 20% of the words were abbreviations and of this 6.8% were inappropriate, ambiguous or unknown.3 Sheppard and her colleagues examined the abbreviation use in pediatrics, and found 221 different abbreviations in 25 handover pages and 479 different abbreviations in medical notes.7 Less than 40% were recognized by the standards they used, the medical dictionary available on the hospital intranet and Mosby’s medical dictionary.8,9 Chemali et al. conducted an audit of abbreviations found in discharge summaries and found that 6 abbreviations were interpreted incorrectly by more than 25% of the general practitioners answering their questionnaire.10 Sinha et al. studied the interpretation of abbreviations from surgery and found that only 43% were interpreted correctly.2 The authors of these articles suggested several possible ways which can be used to deal with this issue, including approved shorthand lists and addressing the issue during intern orientation. Despite extensive literature search, we could not find manuscripts regarding other ways that can be used to prevent the use of unauthorized abbreviations. Suggestions intended to decrease unauthorized abbreviation such as ‘do not use’ lists probably did not have significant effect since physician continue to abbreviate terms frequently as reflected by recent article on the subject.11 In the current study, we examined the frequency of use and the comprehension of abbreviations from admission notes and discharge letters composed by medical and orthopedic surgery residents. The purpose of examining this subject in two specialties was to find out whether and to what extent clinicians from one specialty are familiar with abbreviations used by clinicians from another specialty, a subject that to the best of our knowledge was not studied before. Materials and methods The study included 80 admission notes and discharge letters composed by 44 residents from 3 medical wards and 2 orthopedic surgery wards (20 admission notes and 20 discharge summaries from each specialty). The admission notes and discharge letters were randomly sampled from documents written from June 2016 to July 2016 and all identifying details were removed from the documents. Although collecting the discharge letters and admission notes, we verified that no more than two documents were written by the same resident. We recorded the abbreviations included in every document from the two specialties. Following data collection, the number of different abbreviations and the number of times each abbreviation appeared in the documents from each specialty were calculated. The first sentence containing each abbreviation was used for analysis by three senior physicians and three senior orthopedic surgeons. All clinicians were board certified at least 5 years prior to the study. The senior clinicians graded the abbreviations as common and understandable or ambiguous and unknown. In the cases, where the senior clinicians graded the abbreviation differently, the disagreement was resolved by discussion. The following abbreviations were excluded: (A) the titles Dr. and Prof. were not included since they appear automatically on the heading of every document produced from the electronic patient record. (B) Abbreviations of laboratory test names were omitted since they are part of the table of tests included automatically in the electronic document. (C) Abbreviation of measurements such as mg, mcg and kg were not included since they are standard unit of measure, and their use is allowed even in research manuscripts.9,12 As the documents composed by medical residents were significantly longer, the percentage and not the number of abbreviations is presented in order to compensate for the difference in length. Statistical analysis; in order to examine the association between document type, ward and document characteristics, a mixed repeated measures ANOVA was applied with document type (admission or discharge) serving as the independent variable and ward (medical or orthopedic) serving as the dependent variable. Total number of words in the documents and the percentage of abbreviations served as dependent variables (a separate model for each dependent variable). Associations between frequency data were examined using Pearson’s chi-square test. All analyses were two-tailed and a P-values ≤ 0.05 was considered significant. All analyses were performed using IBM-SPSS21. The study was approved by the Meir Hospital Institutional Ethics Committee. Results The total number of abbreviations found in the 40 admission notes and discharge summaries written by medical residents was 1525 with 80 different abbreviations. The number of abbreviations in the documents written by the orthopedic surgery residents was 493 with 51 different abbreviations. As can be observed in Table 1, the admission notes and discharge letters composed by the medical residents were longer than those prepared by the orthopedic surgery residents (P < 0.001 and P < 0.02, respectively). Table 1 Comparison between admission notes and discharge letters from medical and orthopedic surgery wards Variable  Medical ward  Orthopedic ward  P value  M ± SD  M ± SD  Total number of words   Admission  457 ± 170  187 ± 63  P < 0.001   Discharge  538 ± 193  249 ± 97  P < 0.02  Percentage of abbreviations   Admission  9.3 ± 4.5  6.3 ± 3.4  P = 0.004   Discharge  6.8 ± 1.8  4.9 ± 2.4  P = 0.005  Variable  Medical ward  Orthopedic ward  P value  M ± SD  M ± SD  Total number of words   Admission  457 ± 170  187 ± 63  P < 0.001   Discharge  538 ± 193  249 ± 97  P < 0.02  Percentage of abbreviations   Admission  9.3 ± 4.5  6.3 ± 3.4  P = 0.004   Discharge  6.8 ± 1.8  4.9 ± 2.4  P = 0.005  Abbreviations: M, Mean; SD, Standard deviation. The percentage of abbreviations in admission notes and discharge letters was significantly smaller in the orthopedic surgery compared to the medical group documents (P < 0.005). It is interesting that the percentage of abbreviations was smaller in the discharge letters than in the admission notes (P < 0.01). This may suggest that since discharge letters are read by physicians outside the ward and by patients the residents tried to write them in more ‘formal’ language. The second aim of the study was to compare the comprehension of abbreviated terms. As described in the Materials and Methods Section, the medical and orthopedic surgery senior clinicians graded each abbreviated term from both groups as understandable or unknown. Analysis of the lists of abbreviations revealed that 14% of the abbreviations from the medical ward documents were graded as unknown by the medical ward senior physicians compared to 25% by the senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups the senior orthopedic surgeons graded 8% as unknown compared to 21% by the medical ward senior physicians. These differences were statistically significant. Table 2 lists the 10 most common abbreviations which were graded as understandable by senior clinicians from the same specialty. Examination of Table 2 reveals that some of the abbreviations are used by both groups of residents, although they did not use them in the same frequency. Examples for such abbreviations are status post (S/P), computed tomography (CT) and hypertension (HTN). Other abbreviations were used only by one discipline such as chest radiogram (CXR) by the medical residents and spine (SPN) by the orthopedic surgery residents. The abbreviated term neurovascular (NV) merits further discussion since it belongs to a group of ‘niche’ abbreviations. Table 2 Ten most common understandable abbreviations used by medical and orthopedic surgery residents as graded by senior physicians from the same specialty Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  S/P (status post)  27  S/P (status post)  36  ECG (electrocardiogram)  24  NV (neurovascular)  25  HTN (hypertension)  24  CT (computed tomography)  16  BIL (bilateral)  23  LT (left)  12  BIL (bilateral)  18  HTN (hypertension)  9  CT (computed t omography)  12  BIL (bilateral)  9  DVT (deep vein T hrombosis)  12  SPN (spine)  8  CXR (chest radiogram)  12  USU (usually)  7  CVA (cerebrovascular a ccident)  12  TKR (total knee replacement)  6  CHF (congestive heart failure)  9  ORIF (open reduction internal fixation)  4  Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  S/P (status post)  27  S/P (status post)  36  ECG (electrocardiogram)  24  NV (neurovascular)  25  HTN (hypertension)  24  CT (computed tomography)  16  BIL (bilateral)  23  LT (left)  12  BIL (bilateral)  18  HTN (hypertension)  9  CT (computed t omography)  12  BIL (bilateral)  9  DVT (deep vein T hrombosis)  12  SPN (spine)  8  CXR (chest radiogram)  12  USU (usually)  7  CVA (cerebrovascular a ccident)  12  TKR (total knee replacement)  6  CHF (congestive heart failure)  9  ORIF (open reduction internal fixation)  4  Table 3 includes the five most common ambiguous or unknown abbreviations. The table includes the abbreviations used by both medical and orthopedic surgery residents, as graded by senior clinicians from the same specialty. Some abbreviations, for example, chronic atrial fibrillation (CAF) which was recognized by all medical senior physicians was categorized as unknown ambiguous by the senior orthopedic surgeons. Table 3 Five most common ambiguous or unknown abbreviations used by medical residents and by orthopedic surgery residents and graded by senior physician from the same specialty Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  HRF (Heart failure)  6  PROB (Probably)  4  W (Widow)  4  LE (Lesion)  3  HSM (Hepatosplenomegally)  4  CAF (Chronic atrial fibrillation  3  LTR (Later)  3  LIII (Third lumbar vertebra)  2  PUL (Pulmonary)  3  BX (Antibiotic)  2  Medical residents   Orthopedic residents   Abbreviation (definition)  Frequency  Abbreviation (definition)  Frequency  HRF (Heart failure)  6  PROB (Probably)  4  W (Widow)  4  LE (Lesion)  3  HSM (Hepatosplenomegally)  4  CAF (Chronic atrial fibrillation  3  LTR (Later)  3  LIII (Third lumbar vertebra)  2  PUL (Pulmonary)  3  BX (Antibiotic)  2  Table 4 includes the grading of the senior clinicians of abbreviations from both groups of the documents composed by medical and orthopedic surgery residents. When graded by medical senior physicians the percent of unknown or ambiguous abbreviations in the documents composed by orthopedic surgery residents increased from 8% to 21%. The opposite was found when senior orthopedic surgeons graded the documents composed by the medical residents, the percent of ambiguous or unknown abbreviations increased from 14% to 21%. Table 4 Percentage of abbreviations judged as ambiguous by medical or orthopedic surgery senior physicians Department  Percentage of unknown abbreviations in medical documents (%)  Percentage of unknown abbreviations in orthopedic surgery documents (%)  Senior medical physicians  *8  *21  Senior orthopedic surgery physicians  **21  **14  Department  Percentage of unknown abbreviations in medical documents (%)  Percentage of unknown abbreviations in orthopedic surgery documents (%)  Senior medical physicians  *8  *21  Senior orthopedic surgery physicians  **21  **14  * P < 0.001. ** P < 0.005. Discussion Abbreviations are stylistic markers of the medical jargon. We found that 4.9–9.3% of the words in admission notes and discharge letters were abbreviations. Interestingly, the medical residents used significantly more abbreviated terms than the orthopedic surgery residents. The reason for this difference may be partly explained by short or even lack of the medical history section in documents written by the orthopedic surgery residents. The percentage of abbreviations was smaller in discharge letters in both groups. When comparing admission notes to discharge letters, we found that the Discussion Section was longer and contained fewer abbreviations since part of the abbreviations included in the admission notes were omitted or replaced by the exact terms. This may indicate that the residents attempted to replace some of the abbreviations with the exact term in these documents for clarification. The percentage of abbreviations found in the discharge letters was smaller than that found in other studies. This may be partly explained by the omission of measurement units, titles and laboratory test names.9,12 Additionally, in the EMR system used in the hospital medication names cannot be abbreviated since when typing the first letters of a drug a list of medications that is comprised of the generic name and type of preparation appears and the user must choose one of them. This system eliminates the use of drug name abbreviations and may decrease the number of errors during drug prescription. The second part of the study included investigating the comprehension of abbreviations by senior clinicians from medical and orthopedic surgery departments. We found that each group understood the meaning of more abbreviations from the same discipline than from the other discipline. This finding is worrisome, since it indicates that clinicians from one discipline may have difficulty in understanding documents written by clinicians from another specialty, and thus may compromise optimal patient care. Abbreviations such as MRI may be universally accepted. On the other hand, we found that the abbreviation NV was the second most common abbreviation in orthopedic surgery but was not understood by the medical senior physicians. The orthopedic surgery residents use NV in the physical examination part of the documents as ‘NV normal.’ When examining documents from other institutions we could not find this abbreviated term. This demonstrates a common phenomenon of abbreviations that exists only in one ward or institution and not in another (‘niche’ abbreviations). Additionally, an abbreviation may have several meanings, for example; RA may be interpreted as rheumatoid arthritis, room air, right atrium or right arm. On the other hand, several abbreviations may exist for one term, for example: chronic renal failure may be abbreviated as CRF, CKD and RF. Using abbreviations with several meanings and multiple abbreviations for the same term may also cause misunderstanding of medical documents. Several suggestions were found in the literature regarding proper use of ‘standard abbreviations,’ Sheppard and her colleagues suggested using a list of standard abbreviations based on Mosby’s Medical Dictionary displayed in the department.7 Others have also suggested use of easily accessed lists of abbreviations and reinforcing the proper use of shorthand early in training. As studies from recent years show that the number and type of abbreviations does not decrease, it seems that the suggestions of ways intended to decrease the use of abbreviations that are not understandable or have several meanings did not decrease the use of this abbreviations.11 As impaired patient care and medico legal issues may evolve from the inappropriate use of shorthand, a pragmatic way of resolving the issue may be an administrative decision by the organization or institution to allow the use of authorized abbreviations only. We suggest that a list of approved abbreviations that is composed mostly of terms used in spoken medical language such as CT scan, MRI and AIDS and does not have several meanings should be prepared. These abbreviations list should be incorporated into the EMR as are generic names of drugs and an abbreviation must be chosen from the list, otherwise the writer will not be able use them while typing as is the case with medication names during the prescribing process. Additionally, the awareness of the potential damage to patients and the medico legal implications of widespread shorthand uses among should be emphasized to senior physicians and tutors that teach medical students and residents. The senior physicians and tutors of medical students will be asked to explain why the avoidance of abbreviations which are not universally acceptable and included in the lists of allowed abbreviations is important. As the ability to compose clear and concise documents is critical, we suggest that a course in medical document composition should be included as part of the curriculum in medical schools, as was suggested for learning how to prepare detailed list of problems in the wards for the next shift.13 Conclusion The aim of the study was to assess the frequency, type and comprehension of abbreviations in admission notes and discharge letters composed by orthopedic surgery and medical residents. Abbreviations were extracted from discharge letters and admission notes composed by residents from orthopedic surgery and medical wards. The 50 most common abbreviations were graded by 3 medical and 3 orthopedic surgery senior clinicians as: (1) understandable and (2) ambiguous or unknown. Our findings indicate that abbreviation use is common and their frequency was 9.3 and 4.9% of the total word count in documents composed by medical and orthopedic surgery residents. Additionally, analysis revealed that 14% of the abbreviations from medical ward documents were graded as ambiguous or unknown by medical senior physicians compared with 25% by senior orthopedic surgeons. When abbreviations from orthopedic surgery documents were presented to both groups, senior orthopedic surgeons graded 8% as ambiguous or unknown compared with 21% by the medical senior physicians. Our suggestion is that in order to improve comprehension of medical documents and prevent impairment of patient care, only standard abbreviations should be used in medical documents. Measures should be taken to decrease the use of non-standard abbreviations such as education beginning in medical school and the incorporation of authorized abbreviations to the electronic medical record. Compliance with ethical standards This study was not funded by any entity. Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors and it was approved by Meir Hospital Ethics Committee. Conflict of interest: None declared. References 1 Oxford Online Dictionary. 2007. http://www.oxforddictionaries.com/us/definition/american_english/ (25 June 2017, date last accessed). 2 Sinha S, McDermott F, Srinivas G, Houghton PW. Use of abbreviations by healthcare professionals: what is the way forward? Postgrad Med J  2011; 87: 450– 2. Google Scholar CrossRef Search ADS PubMed  3 Politis J, Lau S, Yeoh J, Brand C, Russell D, Liew D. Overview of shorthand medical glossary (OMG) study. Intern Med J  2015; 45: 423– 7. Google Scholar CrossRef Search ADS PubMed  4 Leaman R, Khare R, Lu Z. Challenges in clinical natural language processing for automated disorder normalization. J Biomed Inform  2015; 57: 28– 37. http://dx.doi.org/10.1016/j.jbi.2015.07.010 Google Scholar CrossRef Search ADS PubMed  5 Spasic I, Livsey J, Keane JA, Nenadic G. Text mining of cancer-related information: review of current status and future directions. Int J Med Inform  2014; 83: 605– 23. http://dx.doi.org/10.1016/j.ijmedinf.2014.06.009 Google Scholar CrossRef Search ADS PubMed  6 Xu H, Wu Y, Elhadad N, Stetson PD, Friedman C. A new clustering method for detecting rare senses of abbreviations in clinical notes. J Biomed Inform  2012; 45: 1075– 83. http://dx.doi.org/10.1016/j.jbi.2012.06.003 Google Scholar CrossRef Search ADS PubMed  7 Sheppard JE, Weidner LC, Zakai S, Fountain-Polley S, Williams J. Ambiguous abbreviations: an audit of abbreviations in paediatric note keeping. Arch Dis Child  2008; 93: 204– 6. Google Scholar CrossRef Search ADS PubMed  8 Online Medical Dictionary via Trust Intranet. Department of Medical Oncology, University of Newcastle Upon Tyne; http://cancerweb.nci.ac.uk/omd/ (10 June 2017, date last accessed). 9 Anderson DM. Mosby’s Medical, Nursing, and Allied Health Dictionary , 9th edn. Mosby, St. Louis, 2012. 10 Chemali M, Hibbert EJ, Sheen A. General practitioner understanding of abbreviations used in hospital discharge letters. Med J Aust  2015; 203: 147, 147e.1-4. Google Scholar CrossRef Search ADS PubMed  11 Awan S, Abid S, Tariq M, Zubairi ABS, Kamal A, Arshad S, et al.   Use of medical abbreviations and acronyms: knowledge among medical students and postgraduates. Postgrad Med J  2016; 92: 721– 5. Google Scholar CrossRef Search ADS PubMed  12 Instruction for Authors. Spine. http://www.editorialmanager.com/spine/default.aspx (10 June 2017, date last accessed). 13 Chu ES, Reid M, Burden M, Mancini D, Schulz T, Keniston A, et al.   Effectiveness of a course designed to teach handoffs to medical students. J Hospital Med  2010; 5: 344– 8. Google Scholar CrossRef Search ADS   © The Author(s) 2017. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oup.com

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QJM: An International Journal of MedicineOxford University Press

Published: Mar 1, 2018

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