Friday, May 7, 2010

The Need for "Responsible Abbreviation Usage" in Hospital Chart Records

Pls start IVF w/ D5LR and reg at 30 gtts/min.
CBR w/o TP. Labs: For CBC, U/A, SE, PT, BT.
Seen these abbreviations in our handwriten Doctor's Orders in patient chart records?
Surprised? You shouldn't be. Abbreviations may already be common in local hospital chart records.

A paper by the author of this blog (which is still to be published) presented as a poster in the latest Asia Pacific Medical Education Conference in Singapore held last February 2010 determined that abbreviations were present in all the patient's histories, PE and Doctor's Orders in the chart records of 2 local hospitals studied.

Non-universally-accepted abbreviations were common such as ECE (equal chest expansion), DHS (distinct heart sounds) and HFD (heredofamilial disease).

Potentially dangerous abbreviations were noted such as d/c or D/C which could mean either as discontinue, discharge or dilatation and curettage.  Some of the other notable abbreviations are OOT (out of town), TYVM (thank you very much), PS (peripheral smear), NCCF (No chocolate-colored food), HOB (head of bed and TFFC (to follow first case).

Abbreviations are more common in the Physical Exam findings than the history itself in the private hospital studied.

Among the text language forms, @ is  usually observed. Yes text forms are beginning to appear in the charts. Considering the charts selected were year 2006 charts, more text language forms may already be present in today's charts.

Abbreviation usage may be discouraged especially in the early medical school years but somehow it persists because it is perceived to be useful despite the known potential dangers. It appears that abbreviations are here to stay. Since abbreviations are difficult to eliminate then perhaps it is better to teach instead responsible abbreviation usage and make guidelines for abbreviation usage.

Abbreviations are important even outside patient care when the patient's case is of legal importance and for the Philhealth insurance. Thus there is really a need to remind medical students of the potential dangers of abbreviations in perhaps a separate topic to promote responsible abbreviating. In this subject, the aforementioned guidelines may be introduced including a local version of the "Do Not Use" list as a standard to be agreed upon probably by doctors of different hospitals and the Association of Philippine Medical Colleges.

In this way also, even physicians from Joint Commission-accredited hospitals will not have a hard time adjusting as to what abbreviations are allowed to be used since there was already prior training in their respective medical schools.