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Medical abbreviations: writing little and communicating less

机译:医学缩写:少写而少交流

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The article by Sheppard and colleagues1 in the March issue of Archives of Diseases in Childhood describes the overuse of ambiguous abbreviations in paediatric note taking. Reading this article led one of us to review a clinic note written earlier in the day describing a "2 yo P here for a RPE w/a recent URI. who c/o ear pain y/d". On further inspection, this note was found to contain 35 abbreviations, all of which were completely unambiguous to the author when the note was written. However, many could certainly cause confusion should any other healthcare providers require information to make clinical decisions about this patient in the future.
机译:Sheppard及其同事1在三月出版的《儿童疾病档案》中的文章描述了儿科笔记记录中模棱两可的缩写的过度使用。阅读这篇文章使我们中的一个人回顾了当天早些时候写的一份临床说明,内容描述为“此处为使用最近的URI的RPE的2岁患者。经过进一步检查,发现该注释包含35个缩写,在撰写注释时,所有这些对于作者来说都是完全明确的。但是,如果将来其他任何医疗保健提供者需要信息来做出有关此患者的临床决策,则肯定会引起许多混乱。

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