ABSTRACT
OBJECTIVE: To identify the number, type, and appropriateness of abbreviations used to write nurse clinical charts (CC) and nursing discharge reports (NDR) in an inpatient unit. METHOD: We performed a descriptive cross-sectional study in an inpatient unit in the Hospital Clínico San Carlos in Madrid in November 2004. A sample of the CCs and NDRs of patients admitted to the unit during the period studied was analyzed. RESULTS: We analyzed 75 episodes, in which 405 abbreviations/acronyms and 9 different symbols were identified among a total of 1,201. Most of the abbreviations (85.7%; 95% confidence interval [CI] 81.9-88.8) were not included in the "Dictionary of medical abbreviations and other acronyms". For more than half of the abbreviated terms (58.5%; 95% CI: 53.7-63.2) several different abbreviations were used; the median number of abbreviations for the same term was 5 (P25: 2; P75: 4). CONCLUSIONS: A high percentage of the abbreviations used were nonstandard and their meaning had to be deduced from the context. Although only a small percentage of abbreviations were found in the NDRs, abbreviations should not be used in this type of document.
