Interpretation and Misinterpretation of Medical Abbreviations Found in Patient Medical Records: A Cross-Sectional Survey (2024)

Monitoring Editor: Alexander Muacevic and John R Adler

Abstract

Keywords: interpretation, cross-sectional survey, multidisciplinary team, ambiguity, alternative definitions, patient medical records, medical errors, medical abbreviations

Introduction

The use of medical abbreviations has been in practice since the development of mainstream medicine.Medical abbreviations are used in all departments within the hospital setting and on discharge [1]. Withhealthcare professionals making up their own abbreviations, there are a growing number of non-standard abbreviations being used in patient medical records and prescriptions. People useabbreviations to save time, to fit words or phrases into small spaces, or to avoid the possibility ofmisspelling words. However, abbreviations are sometimes misunderstood, misread, or misinterpreted.Some abbreviations can have more than one contradictory or ambiguous definition [2].

Previous questionnaire-based studies have demonstrated that the use of abbreviations in patientmedical records by doctors and nurses is high, and there is significant variability in the interpretation of these abbreviations among both professionals [3,4]. A study looking at the use of abbreviations in surgicalnote-keeping demonstrated that abbreviations are being used regularly and often inappropriately. Over90% of surgical notes had at least one abbreviation, and at no time was the abbreviation ever fullydefined [5].

The association between the use of abbreviations in medical prescribing and the potential for harm tothe patient is well established [6]. The use of electronic prescribing has reduced prescription-inducedmedical errors by stopping the use of non-standard abbreviations during prescribing [7]. However, it isonly recently that attempts have been made to control the use of abbreviations in patient medicalrecords. Standard lists of “use” and “do not use” abbreviations have been created, and some healthcareinstitutions have created their own specialized lists of abbreviations that can be used in patient medicalrecords [8,9].

While there are anecdotal examples of medical abbreviations resulting in medical errors, the potentialfor harm to the patient from improper communication due to medical abbreviations cannot beunderstated. Additionally, patient care is multidisciplinary, so there should be no room for ambiguity inpatient medical records. Therefore, the aim of this survey was to assess individual interpretations andmisinterpretations of a list of medical abbreviationsfound in patient medical records, and thereby increase awareness of the growing use of non-standard abbreviations in patient medical records.Findings from this survey could provide impetus to limit the use of non-standard abbreviations in patient medical records and thus limit the potential for harm to patients.

Materials and methods

Ethics approval was sought through the Research & Development Department of our institution. This cross-sectional survey did not require ethical approval. It was registered with our Quality, Governance and Compliance Department as part of a Service Evaluation Project. Verbal consent was obtained from all volunteers. Volunteerswere assured of strict anonymity and confidentiality during this study.

This was a one-day cross-sectional survey. Anonymized questionnaires containinga list of 20 abbreviationswere given to aconvenience sample of consultant physicians, doctors-in-training, and nurses who rely on accuratemedical record-keepingwhen contributing to patient care. Volunteers were from 10 medical wards and were chosen because they were available and willing to participate on the day. The abbreviations were preselected from a random set of patient medical records; chosen based on the fact that their definitions were unknown to any one of the study organizers. Theintended definition of each abbreviation was derivedfrom the healthcare workers who usedthem in the medical records. Volunteers were therefore asked to define each abbreviation in full. Volunteers weregiven 15 minutes to complete a questionnaire without any conferring. If they could not define theabbreviation, they could simply put “do not know”. Volunteers were assured that this was not a test ofknowledge.

Analysis

A provided definition was either the intended definition or an alternative definition,which was completely different in terms of text and meaning.For each volunteer, the number of abbreviations paired with their intended definition was collated (ascore of one mark was given for each). For each abbreviation, the number of volunteers who providedthe intended definition wascollated. The number of alternative definitions for each abbreviation wasalso collated. For an abbreviation to be regarded as “generally accepted”, it was arbitrarily expected thatat least 50% of volunteers would provide the intended definition for that abbreviation.

Results

We had 46 volunteers who each completed a questionnaire. Volunteers were made up of 15nurses, 15 doctors-in-training, and 16 consultant physicians. All the volunteers had regular access topatient medical records while contributing to patient care.

Table ​Table11 shows the list of abbreviations with intended definitions. Figure ​Figure11 shows the number of volunteers who wrote down the intended definition for each abbreviation. The abbreviation “T2MI” had the maximum number of volunteers who wrote the intended definition (Type 2 Myocardial Infarction), and this was 40 volunteers (86.96%).The abbreviation “AP” had the minimum number of volunteers who wrote the intended definition(Abdominal Pain), with a response of zero. Only four of the 20 abbreviations (T2MI, CBG, BIBA,and LTC) had more than 50% of volunteers providing the intended definition; and therefore regarded as “generallyaccepted” (Figure ​(Figure11).

One point was allocated for each intended abbreviation provided on the questionnaire. Table ​Table22 showsthe mean (range) scores out of 20 obtained by the three healthcare groups (consultant physicians,doctors-in-training, and nurses) for writing down the intended definitions for the list of abbreviations.The maximum score achieved among the volunteers was 12 out of 20 (60%), and the minimum scoreachieved was 2 out of 20 (10%).

The overall mean score achieved by the volunteers was only 6.39 out of 20 (32%). Only 25% of thevolunteers achieved a score above 10 out of 20; therefore, three-quarters of the group were unable toprovide the intended definition for half of the abbreviations on the list.

Alternative definitions

Any other definition written down in place of the intended definition (different in terms of text andmeaning) was labelled as an alternative definition. Table ​Table33 demonstrates the alternative definitions and thenumber of volunteers who wrote down these for each abbreviation. In total, 15 of the 20 abbreviations(75%) had one or more alternative definitions. The abbreviation AP had the highest number ofalternative definitions (seven). Second to that was the abbreviation FND, which had five alternativedefinitions.

The abbreviation “LBP” had the highest number of volunteers (56.52%) who provided an alternativedefinition (Lying Blood Pressure) instead of the intended definition (Low Back Pain). Second was theabbreviation “OM”, which had 47.83% of volunteers who provided an alternative definition (One in theMorning) instead of the intended definition (Osteomyelitis). In third and fourth place were the use of thealternative definitions “Functional Neurological Disorder” and “Capillary Blood Gas” for theabbreviations “FND” and “CBG” instead ofthe intended definitions (Focal Neurology Detected and Capillary Blood Glucose), respectively.

Discussion

We administered questionnaires containing a list of 20 abbreviationsused in patientmedical records to a group of doctors and nurses involved in patient carein a secondary care hospital.Volunteers were asked to provide the definitions of the abbreviations presented. This survey demonstrated that none of the volunteers were able to provide the intended definitions for all 20 abbreviations on the list, and none of the abbreviations had the intended definition provided by everyvolunteer. Less than 25% of volunteers knew more than 50% of the abbreviations presented to them.Only 20% of the abbreviations had more than 50% of volunteers able to provide the appropriateintended definition: therefore, only these abbreviations (T2MI, CBG, BIBA, and LTC) could be regarded as “generally accepted”. Additionally, 75% of the abbreviations had one or more alternative definitions and were thereforeambiguous.

This survey revealed several examples of how multiple interpretations of a single abbreviation can lead to miscommunication and medical errors, for example, the abbreviation "T2MI" for Type 2 Myocardial Infarction being interpreted as Type 2 Diabetes Mellitus by some volunteers; the abbreviation "CBG" for Capillary Blood Glucose being interpreted as Capillary Blood Gas by a significant number of volunteers; the abbreviation "FND" for Focal Neurology Detected being interpreted as Functional Neurological Disorder by several volunteers; and the abbreviation "TTWB" for Toe Touch Weight Bearing being interpreted as Total Weight Bearing by some volunteers.

The results of this survey mirror that of previously published studies. In a study evaluating the understanding of common medical abbreviations among doctors from several departments in an academichospital, the findings suggested that the understanding of medical abbreviations across medical departments is below standard. This was even worse for non-standard abbreviations [10]. The authors went onto suggest that the use of non-standard medical abbreviations should be discouraged [10]. Anotherstudy of common abbreviations used in surgical inpatient admissions demonstrated similar poor resultsand concluded that the use of an unambiguous and approved list of abbreviations is required to ensuregood communication in patient care [11]. A recent Danish study found that manyabbreviations had multiple meanings, and that writing a sentence with abbreviations saved 20 seconds, while comprehensionof an abbreviated sentence took an extra 12-85 seconds [12]. The authors went on to suggest solutionssuch as: embracing and expanding the use of abbreviations, the introduction of artificial intelligence tointerpret abbreviations, or the use of speech recognition software in all Danish hospitals [12].A largeAustralian study, using an abbreviation extracting software revealed that one-third of abbreviationsused in general medical discharge summaries were ambiguous [13]. Although studies evaluating the useof non-standard abbreviations are few, they all portray the same message. More than 50% of medicalabbreviations, especially non-standard ones, are ambiguous, and should not be used in patientmedical records.

During this survey we received several anecdotal reports of some abbreviations being misunderstood or misinterpreted, resulting in minor medical errors; however, such events were never officially reported. Webelieve that abbreviations used in patient medical records should be standardized and fully accepted byeveryone who has access to the records for the provision of patient care. Patient care is multidisciplinary,thus multiple healthcare groups have access to patient medical records in hospitals. Healthcare staffshould not have to keep looking up the meaning or asking another professional for the full meaning ofabbreviationsused in patient medical records; this is time-consuming. Medical errors and near misses arising fromthe use of abbreviations should be officially reported.

Survey limitations

Firstly, the abbreviations were assessed out of contextby volunteers. Volunteers may have been able to define the abbreviations if presented within context.Further studies should be designed to assess the understanding of abbreviations presented within context. Secondly, the intended definition of anabbreviation was derived beforehand from the healthcare workerwho used it in the patient's medical records. Therefore,it is possible that the derived definition was an alternative definition from the start. This will be a continuousproblem with the growing number of non-standard abbreviations. Thirdly, the volunteers were made up of doctors and nurseswho may have been able to recognize abbreviations specific to their working group. We only includedvolunteers working within the Department of Medicine. Fourthly, as this was a convenience sample, a sampling bias cannot be completely ruled out. The sample may not be typical of the total doctors and nurses workforce in our institution, and findings may not apply to other healthcare institutions. Patient medical records are multidisciplinary and accessed by multiple healthcare groups and across multiple departments. Therefore, further studiesusing random sampling methods should include a more diverse group of healthcare professionals from different settings anddepartments.

Conclusions

There is a growing use of non-standard abbreviations in medical practice. A majority of abbreviations are not recognized among user groups and a majority have multiple alternative definitions. The use of abbreviations in healthcare can lead to poor communication and misinterpretation, which can result in medical errors.When writing an abbreviation, one should consider the following points: (i) Is this a standard abbreviation? (ii)Will everyone, including the patient be able to interpret the abbreviation? (iii) Is abbreviating necessary?(iv) Will abbreviating really save time?

Medical errors or near misses resulting from the use of abbreviations in patient medical records shouldbe officially reported. This will help in understanding the extent of the problem and in formulating solutions. Additionally, healthcare institutions should provide clear policies on the use of abbreviations, and introduce initiatives todiscourage the use of non-standard abbreviations, such as abbreviation-free periods or standard abbreviations awareness programs.

Acknowledgments

I would like to acknowledge the kind contribution from the volunteers who took part in this study.

Notes

The authors have declared that no competing interests exist.

Human Ethics

Animal Ethics

References