Medical abbreviations: Are your patients complaining?
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The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule gives patients the right to examine their medical records and request corrections and additions to those records.
HIPAA also exists for another reason: to safeguard patient information.
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When the act became law in 1996, not many patients immediately accessed their medical notes. This more than likely was due to an initial lack of awareness.
Fast forward to 2016, when the 21st Century Cures Act made sharing electronic health information the expected norm in health care by authorizing the HHS secretary to identify “reasonable and necessary activities that do not constitute information blocking.”
It should not be surprising that patients began to read their medical notes.
Four years later, as COVID-19 pandemic-related lockdowns took effect and patients looked for things to keep them busy at home, they found medical information at their fingertips.
Easy but unhelpful
I bring this up because in a brief discussion with one of my colleagues, he mentioned that one of his patients complained about the inability to understand his notes because of abbreviations. We use abbreviations in the medical world to save time and space while writing/typing in patients’ medical records. Frankly, they are an easy but unhelpful way to name things.
Although abbreviations had been limited to prescriptions, they have become very common in all aspects of medical documentation. As specialties have evolved, each has developed a set of commonly used abbreviations within their fields of expertise that may not be recognizable to those working in other fields.
Abbreviations allow us to avoid repeating words, thereby making the text easy to read. However, they can be misunderstood, misread or interpreted incorrectly. Their use lengthens the time needed to train health care professionals, results in wasted time tracking down their meaning, sometimes delays patient care and potentially can result in patient harm.
Think about the number of medical abbreviations we use in medical notes. WBC, RBC, LUQ, RUQ, IM, IV, PO and q2h are just a few. My commentaries are usually 700 to 800 words in length. At this point, I could finish this commentary with a list of medical abbreviations and still have some remaining.
A noteworthy consideration
I understand that this was only one patient complaint. But perhaps you have heard the same from your patients. If so, should we alter our notes to make them more understandable for our patients?
A recommendation to make notes less confusing for patients gives the example of spelling out SOB. I emphasize SOB in the context of medical terminology.
I suppose it would not take more time to write out shortness of breath. However, would you really want to write out EEG, BSO or TAH? Perhaps it depends on the number of abbreviations you use, or maybe you are telling yourself you do not have the time.
One must also consider that we are in an era of knowledge overload post-COVID (not really over) with a lack of resources and personnel along with caretaker burnout. Why change now under these strenuous circumstances? I guess it comes down to physician choice and whether your patients are complaining or not.
Finally, you might accuse me of being out of touch, as people make up abbreviations all the time. You might see a “u” replacing “you,” “4” instead of “for,” “BTW” rather than “by the way,” and “r” for “are.”
I remember years ago watching my youngest daughter type a text message with the above abbreviations. When I asked her what they were, she explained their meaning.
“I put you through 4 years of college and this is the English language you use?” I responded.
“Everybody uses these,” she said.
Stay safe.
References:
- Esch T, et al. BMJ Open. 2016;doi:10.1136/bmjopen-2015-010034.
- Klein JW, et al. Am J Med. 2016;doi:10.1016/j.amjmed.2016.05.015.
- Public law 114-255. 21st Century Cures Act. Available at: www.congress.gov/114/plaws/publ255/PLAW-114publ255.pdf. Accessed Feb. 16, 2023.
For more information:
Nicholas J. Petrelli, MD, FACS, is Bank of America endowed medical director of ChristianaCare’s Helen F. Graham Cancer Center & Research Institute and associate director of translational research at Wistar Cancer Institute. He also serves as Associate Editor of Surgical Oncology for HemOnc Today. He can be reached at npetrelli@christianacare.org.
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Public law 114-255. 21st Century Cures Act. Available at: www.congress.gov/114/plaws/publ255/PLAW-114publ255.pdf. Accessed Feb. 16, 2023.
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