A descriptive study of the knowledge of nurses and doctors of clinical abbreviations in hospital discharge reports

Abstract

Introduction: Medical Records have a large number of abbreviations and doctors and nurses may not be aware of their meaning, which could compromise patient safety.

Objective: To evaluate the knowledge of doctors and nurses of the clinical abbreviations in medical discharge reports.

Methods: Observational-cross sectional study through a questionnaire developed ad hoc for doctors and nurses from Hospital Universitario de Fuenlabrada. The content and logical validity of the questionnaire was assessed. The questionnaire was completed anonymously and voluntarily. The questionnaire was also distributed online to the professionals' corporate emails. The questionnaire included sociodemographic variables and 14 abbreviations present in medical discharge reports. The data were obtained from the Electronic Clinical Record.

Results: Out of a total of 756 professionals, the questionnaire was answered by 68 doctors and 86 nurses (n=154).The mean age of the professionals was 40.58 years (SD ±7.54), and the mean number of years of professional experience was 17.10s (SD ±7.37). The professionals gave an average percentage of correct answers of 35.84%. Doctors gave 55.94% of the correct answers, and nurses 23.17%. The abbreviations for which the most errors occurred were SNG, NPIM, EEA, RCP, with a success rate of 5.19%, 6.49%, 6.49% and 7.79%, respectively.

Conclusions: The identification of the abbreviations in medical discharge reports by doctors is superior to that of nursing staff. Overall the knowledge of abbreviations in both professionals is low.

Keywords: Abbreviations; Abreviaturas; Hospitales; Hospitals; Informe de alta; Medical records; Patient discharge summaries; Patient safety; Registros médicos; Seguridad del paciente.