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VITAL patient information could be lost in translation because hospital discharge letters include abbreviations that many GPs are not familiar with, according to new MJA research.
The retrospective audit found that abbreviations used in hospital electronic discharge letters were not understood by up to 47% of GPs. (1)
The researchers said their findings highlighted an area that could contribute to patient morbidity or mortality because of miscommunication.
“It would be imprudent to ignore the magnitude of these findings and not act to minimise the potential for problems”, they wrote.
Dr Nathan Pinskier, chair of the Royal Australian College of General Practitioners national standing committee on e-health, said the use of non-standard abbreviations was a common problem.
“Clinicians or institutions seem to develop their own abbreviations over time, which may or may not be understood by other clinicians”, Dr Pinskier told MJA InSight.
“If clinicians don’t understand terms they tend to ignore them or they pretend they do [understand], which creates risk and may lead to inappropriate decision making.”
The research involved an audit of abbreviations used in 200 sequential electronic hospital discharge letters issued in December 2012 from Nepean Hospital, a Sydney tertiary referral centre.
Local GPs were then surveyed about their understanding of the 15 most commonly used abbreviations and five less frequently used but clinically important abbreviations.
Six abbreviations were incorrectly interpreted by more than a quarter of the 155 respondents. The abbreviation SNT (soft, non-tender) was misinterpreted by 47% of GPs; TTE (transthoracic echocardiogram) by 33.3%; EST (exercise stress testing) by 33.3%; NKDA (no known drug allergies) by 32.6%; CTPA (computed tomographic pulmonary angiography) by 31.1%; and ORIF (open reduction and internal fixation) by 28%.
Dr Danika Thiemt, chair of the AMA Council of Doctors in Training, was surprised by the findings.
“I work 100% in public hospitals and none of the abbreviations were a huge surprise to me. It’s very worrying that there is this mismatch between the people writing the letters— the doctors in training — and those receiving them — the GPs”, Dr Thiemt said.
She said the move to e-health records would provide an opportunity to better define terms, but ensuring that communication about patient care was clear and well understood across the health care system should be the focus of all clinicians.
“Good communication is good health care, and this should be the basis of all interactions between not only doctors and patients, but between health care teams. It’s vitally important that we communicate properly between our hospital system … and our primary care givers.”
Dr Thiemt supported the continued use of abbreviations in hospital discharge summaries because they enabled time-pressed hospital doctors to convey a lot of information in a concise manner.
She acknowledged that it was important to ensure the people using abbreviations “know what they mean, and the people receiving the summaries can readily interpret them”.
Dr Sara Bird, MDA National manager of medicolegal and advisory services, said the study was a useful reminder that electronic notes were not immune to the misinterpretations that had sometimes arisen in handwritten notes.
She said the audit suggested that “a whole language” had developed in hospital settings, which remained foreign to community-based clinicians.
“There hasn’t perhaps been a lot of consideration as to what the end-user makes of that information. The way things are recorded in the hospital setting is going to be different to what’s recorded in a general practice setting,” Dr Bird said, adding that many of the junior medical officers writing discharge summaries would have never worked in community practice.
While MDA National had not received complaints relating to the misinterpretation of abbreviations used in electronic discharge summaries, Dr Bird said, in the event of an adverse outcome, the medicolegal onus would lie with both the doctor who had written the summary and the doctor who had received it.
Dr Pinskier said that in his role as medical director of an after-hours deputising service, he encouraged doctors to write out the clinical notes in full, with the exception of well-recognised clinical abbreviations, such as AMI for acute myocardial infarction.
“It takes longer, but it’s much clearer and reduces confusion,” he said.
Measures to ensure clear communication between the hospital and community health sectors should be undertaken “sooner rather than later”, Dr Pinskier said.
The first step would be to agree on a set of key terms and circumstances where it would be appropriate to abbreviate them. Including standardised terms in medical software would also need to be accompanied by education for doctors.
“It’s a question of understanding the clinical process of documentation … looking at the workflow, how documents are created and understanding what the common abbreviations are”, he said
(Photo: tzahiV / iStock)
Maybe we all need to take stock of our communication skills.
I have been guilty of making abbreviations in discharge summaries especially when I had 20 to do at once.
Likewise I have been the recipient of many one line ‘please do the needful’ referrals.
Hi, “Disregard”. Are we really limited to the discharge summary for communication? It’s common practice in EDs to directly call the GP for clarification and additional information about the referral or the patient’s background (at least during the day, when they are available). Why not call the hospital treating team, or the consultant looking after the patient, to discuss any outstanding questions?
I’d be lucky if one out of ten questions in our admission letters are referred to or answered in the very few discharge summaries that ever make it to our surgery without us having to fax a written request to the hospital after having sent the patient there with a comprehensive GP assessment.
Can fully understand why many GP’s simply write one sentence admissions or none as it does not seem to make one bit of a difference how much effort you put into the admission or how specifically you detail the patient history.
Are we never able to celebrate improvement? We’ve progressed a long way from the days of my junior years, when the GP got a the last copy of a hand-scrawled discharge summary. What is produced in hospitals these days is legible, contains more reliable information but – yes – can still be improved. The abbreviations reflect the hospital environment. Conversely, letters from GPs to hospital often list medications in brand-name format, leading hospital providers to have to look them up.
It should be noted that the more legible letters generated from information systems in hospitals are much slower to produce than hand-written letters. Typing is not the problem (especially for the current generation), but the need to open multiple screens in a cumbersome system.
Both general practice and hospital practice involve their own priorities and time constraints. The pressure of time that leads to use of abbreviations is the same driving factor that leads to a referral letter hastily written on a prescription pad – or no letter at all.
Maybe the solution is to produse a dictionary of accepted abbreviations, and circulate it widely. And to have empathy for colleagues.
Health Information Managers and previously Medical Record Managers have utilised documentation in medical records in Australia for over 50 years for many purposes. Health Information Managers have been promoting quality documentation in paper medical records and more recently electronic health records. They should all adhere to the same rigid standards. The medical record is the pivot point of communication amongst health professionals and provides transparency for patients. The Health Information Management Association of Australia publishes a Dictionary of Abbreviations and perhaps this is the opportunity for the Australian Government to regulate its use in health entities and particularly for use on the My Record.
In the middle 1950s as student, our physician tutor suggested that we should not use abbreviations. After a short pause he added perhaps except for BP. British Pharmacopeia came the immediate response. Enough said!
Letters and summares are meant to be forms of communication. If they are illegible or contain non-universal abbreviations (or both), they are dangerous.
Like Peter Finch, in the movie “Network”, “I’m as mad as hell, and I’m not going to take this anymore!” So, now, when I receive an incomprehensible letter from a hospital or clinic or private specialist, I fax it back to them asking for a revision, written in plain English, free of local in-hospital or in-specialty patois..
If it happens again, I include in my fax, George Orwell’s, Six Rules for effective writing:
(i) Never use a metaphor, simile, or other figure of speech which you are used to seeing in print.
(ii) Never use a long word where a short one will do.
(iii) If it is possible to cut a word out, always cut it out.
(iv) Never use the passive where you can use the active.
(v) Never use a foreign phrase, a scientific word, or a jargon word if you can think of an everyday English equivalent. (my emphasis)
(vi) Break any of these rules sooner than say anything outright barbarous
I usually replace No 6 with “Never use an acronym without writing out what it means, in full, the first time it is used in a letter or report”
Dear Dr
Your pat, Mr JB, was BIBA to A&E last night c/o SOBOE and SOA. He had a PH of SVT, CHD, CCF, T2DM, TIA, TLE, AAA, CAL, OSA, bilateral THRs, L-TKR, R-#TibFib with ORIF, PMR, TURP and VVs.
OE – RR 30, P 88 AF; SOA +++; JVP 3cm, AB 6ICS AAL, LV++, HS-2, sys murmur +++ c/c AS; ECG – AF, LAD, LAHB and RBBB.
CXR – UL diversion, CTR 22:38. GGT 120; LDH 380, ALT/AST mildly elevated; Hb 8, MCV 65, ESR 88 and eGFR 18
He had dig, Lasix, roids, O2 and TLC.
He was d/ced this morning on his usual meds with cardiac, renal, respiratory, vascular, endocrinology and fracture clinic to be arranged by usual GP.
HTH.
JRMO
I agree with the previous comments that communication between hospitals and General Practice is extremely important. Interesting I work in a regional centre as a GP in NSW for the past 19 years and none of the abbreviations are unfamiliar to me and in fact I use some of them as short cuts in my GP notes as they are very familiar in our area. In part this may relate to familiarity over many years with expoure to local Specialists letters and Hospital discharge summaries. It would be benificial to have set abbreviations that have universal interpretation but until then Junior doctors in Hospitals need to ensure that full information is communicated. In our town region we have started to invite Interns into General Practice as part of their orientation to understand this amongst other issues.
ROTFLSHMSFOAIDMT = Rolling on the floor, laughing so hard my sombrero falls off and I drop my taco.
This is a problem that could be easily addressed by amending the discharge summary software to include a list of abbreviations, and once the letter is written to change these to their full forms by ticking a box. Each doctor could keep their own list of acronyms but everyone would still be able to read and understand the end result.
Another example of bureaucratic systems letting the teams down and creating more barriers to communication.
A very significant problem, is the same abbreviation can have different meanings in different contexts, and even from hospital to hospital. Abbreviations must NEVER be used in communications to GPs in order to prevent possibly significant errors. Doctors who write reports using abbreviations or acronyms must be held legally responsible if such reports result in patient management errors.
The most worrying abbreviation is the one that simply forgoes the discharge summary altogether. I wouldn’t mind the abbreviations half as much if it weren’t for the total lack of communication which seems to put the patient at much higher risk of treatment failures.
And if GPs struggle, what aboutt he patient who wants to understand their condition and treatment? They can’t get past the jargon, and their GP can’t explain it to them.
There is a potential for fixes in discharge summary writing software. If there were an automated search for abbreviations and acronyms, the program could challenge the typist to confirm each one (on first use). Then the writing software could either replace or footnote those abbreviations…
Surprising this does not exist already given the risks.
This is an issue commonly recognised by Health Information Managers working in hospitals who try to discourage the use of abbreviations for safety and quality reasons. The Health Information Management Association of Australia publishes of comprehensive list of medical abbreviations and acronyms – see Publications at http://www.himaa.org.au
This audit comes as a timely reminder to us that we all need to pay attention to our communication skills, not just in the written word, but also in our speech with our colleagues, other health professionals and our patients. As a consultant general surgeon in a busy hospital, I am constantly subjected to a barrage of abbreviations, acronyms and made-up words which I am expected to understand immediately. It is as if our junior staff are speaking to us in text messages. My only defence is to fire back a few – and there are quite a few interns who are not familiar with the abbreviation EST – particularly coming from a general surgeon!
I mark RACGP exams. Candidates will often use non-standard abbreviations in their answers despite repeatedly being advised not to. A typo in a word will usually still be understood by an examiner, but a typo in an abbreviation will often make it incomprehensible.
Rule of thumb, if a google search of an abbreviation doesn’t come up with a clear, non-ambiguous meaning, its not a real answer, and is marked wrong. Perhaps the same standards could be applied to hospital discharge letters?
I couldn’t agree more that it is a serious problem. I had to ring the hospital on one occasion to enquire as to the meaning of the abbreviated message (don’t remember it specifically now as there have been several) and not only did it describe a serious problem I would have missed if hadn’t enquired, but I was disparagingly made fun of by the the staff returning my fax.
Being a recently retired Ophthalmologist, who sometimes has to think twice about abbreviations at Scientific Conferences in my own Specialty, disrupting my concentration on the next point being made, I very much appreciate the importance of this, with the added factor of patient safety and best manageent that is involved here.
Could the AMA, and Hospitals get together and establish an agreed list of “abbreviations”, (reviewed and updated regularly) for wide electronic dissemination?
I couldn’t agree more. Abbreviations are a real problem. Particularly younger collaegues seem to think they are very cool. However discharge letters and other clinical letters are not text messages. It would help tremendously if recurrent long words are spelt out propperly first time they appear in the text with the abbreviation in brackets behind it. Further use of the abbreviation would then make some sort of sense.
This is a real issue, and it applied to letters from some speciality services as well as to the discharge summaries, such as understanding reports from radiotherapy services.
They sometimes read as if written for their own benefit/ records rather than communication with health professionals outside their subspecialty area.