Abbreviations & Acronyms in the Medical Record - Part Two of a Risk Management Series
Timothy R. Bone, President, MedMal Direct Insurance Company // June 05, 2011
It is the purpose of this Risk Management Series to focus on those non-clinical issues perceived to be influenced by changes in the individual or collective behavior of physicians and other healthcare providers. As expressed in the initial article in this series, 50% of the lawsuits arise from communication problems between human beings, 30% from systems errors and only 20% from actual clinical issues. The goal is to thus address the 80% of the problems arising from administrative or managerial shortcomings as opposed to those rising from clinical knowledge or judgement.
And though the source may be non-clinical, the overall solution must include an incentive-driven provider; that is, the physician involved in the patient’s care. These incentives should decrease the physician’s overhead costs, should enhance the physician’s professional reputation and should avoid simply ordering more expensive diagnostic tests as the answer to the problem. As a highly experienced (i.e., very old) physician recently said to me: “Once the diagnosis has been made, ordering an additional test will only change that diagnosis 5% of the time.”
Following this logic, this series presents problems and solutions via the scientific method: we strive to uncover the epidemiology of the problem, identify the cause(s), quantify them and implement a solution that utilizes prevention rather than simply ordering more tests.
ABBREVIATIONS & ACRONYMS IN THE MEDICAL RECORD
Issue: Incorrect interpretations of abbreviations and acronyms in the medical record by healthcare providers who use those records.
Solution: Minimize the use of abbreviations and acronyms in the medical record – even though each hospital or clinic may have a list of “approved abbreviations”.
1. Obtain a sample of 50 records of patients recently treated at the hospital, clinic or office.
2. Select one page of progress notes and one page of order sheets from each record and identify the abbreviations and acronyms used on each page.
3. List and total all abbreviations and acronyms used – use one page for those found on the progress notes and one page for those found on the order sheets.
4. Compare all listed abbreviations and acronyms with those on the approved abbreviation list – make sure to list and provide the total for all those that agree with the approved list as well as list and provide the total for those that do not agree with the approved list.
5. Divide all results by the sample size (n = 50) to obtain derivative rates – that is, the number of unapproved abbreviations per chart.
Actions to Be Taken:
1. If no abbreviations or acronyms have been used, then so notify the Medical Executive Committee at the next meeting.
2. If only approved abbreviations are used, emphasize that in your report to the Medical Executive Committee at the next meeting.
3. If problems exist, discuss how to minimize the use of abbreviations and acronyms (especially those not on the approved list), implement the solution(s) and revisit the issue after 3 months. Remember to report the revisited results to the Medical Executive Committee at that time.
Added Point of Emphasis:
The approved list of abbreviations may also be a problem. One hospital risk manager obtained a random sample of approved abbreviations and distributed that sample to the medical staff for deciphering. Only one staff member in 58 respondents could interpret half of the items. In a similar vein, for 20% of the items listed, only half of the respondents could identify the meaning of the abbreviation or acronym.
Though Tort Reform will be of assistance in the overall reduction of the frequency and severity of medical malpractice lawsuits, it is important that we eliminate, or at least mitigate, the causes of medical malpractice at the “grass roots” level; that is, at the level of administrative protocols, systems management, and the behavior of healthcare practitioners. By assuming active roles in this process, practitioners at all levels can reduce the frequency and severity of medical malpractice lawsuits; and can thus reduce the financial and emotional costs that medical malpractice allegations bring to medicine.