Abbreviations in medical records: arguments for and against

Abstract

There is often a need for fast and effective communication in modern medicine. Time is often critical when providing care to multiple patients. Medical abbreviations are a form of shorthand that allows healthcare professionals to communicate with one another easily. However, the time and expense of writing acronyms are reduced in case they are clear and familiar to every person involved in communication. Misunderstanding between members of the medical staff often lead to misinterpretations of acronyms and hazard to patients’ health and lives. The aim of this study is to identify and analyze such interrelated phenomena as positive and negative sides of using abbreviations as a way of terminology in medicine, arguments of each of the positions, in order to reduce negative consequences of using abbreviations in modern medical documentation. The material of the study is abbreviations used in modern medical practice. The method of continuous sampling of medical abbreviations from scientific literature and medical documentation was used. The results of the study showed that the most common errors associated with the use of medical abbreviations were the ones in prescribing, incorrect dose/quantity and incorrect preparation of medication. About 80 % of the abbreviations contained in the notes and statements that were handed out were unclear to patients and required clarification by health care providers. Medicine must be based on accurate and correct information, literacy of professional actions, and a sense of the highest responsibility. In this regard, it is necessary to use only standard abbreviations and introduce a ban on the use of abbreviations with ambiguous interpretation. Information in prescriptions, instructions, and statements should be clear and unambiguous, in order to avoid awkward and mundane situations affecting the quality of patients’ perception of the information. All of these factors can contribute to the improvement of the quality of medical care and the patient’s quality of life accordingly.

Keywords

• abbreviation
• medical records
• arguments
• polysemy
• homonymy
• decoding