ABSTRACT
INTRODUCTION: Medical Records have a large number of abbreviations and doctors and nurses may not be aware of their meaning, which could compromise patient safety. OBJECTIVE: To evaluate the knowledge of doctors and nurses of the clinical abbreviations in medical discharge reports. METHODS: Observational-cross sectional study through a questionnaire developed ad hoc for doctors and nurses from Hospital Universitario de Fuenlabrada. The content and logical validity of the questionnaire was assessed. The questionnaire was completed anonymously and voluntarily. The questionnaire was also distributed online to the professionals' corporate emails. The questionnaire included sociodemographic variables and 14 abbreviations present in medical discharge reports. The data were obtained from the Electronic Clinical Record. RESULTS: Out of a total of 756 professionals, the questionnaire was answered by 68 doctors and 86 nurses (n=154).The mean age of the professionals was 40.58 years (SD ±7.54), and the mean number of years of professional experience was 17.10s (SD ±7.37). The professionals gave an average percentage of correct answers of 35.84%. Doctors gave 55.94% of the correct answers, and nurses 23.17%. The abbreviations for which the most errors occurred were SNG, NPIM, EEA, RCP, with a success rate of 5.19%, 6.49%, 6.49% and 7.79%, respectively. CONCLUSIONS: The identification of the abbreviations in medical discharge reports by doctors is superior to that of nursing staff. Overall the knowledge of abbreviations in both professionals is low.
Subject(s)
Abbreviations as Topic , Medical Staff, Hospital/statistics & numerical data , Nursing Staff, Hospital/statistics & numerical data , Patient Discharge Summaries , Adult , Clinical Competence/statistics & numerical data , Cross-Sectional Studies , Electronic Health Records , Female , Humans , Male , Patient Safety , Surveys and QuestionnairesABSTRACT
La necesidad de incluir un mayor número de historias clínicas en el local asignado para archivo y localizar en estos con mayor rapidez la información de valor que se desea de hospitalizaciones anteriores, propició un estudio encaminado a resolver esta dificultad, el que recomendó sustituir la hoja de egreso vigente, por otro formulario diseñado expresamente, denominado Informe de Alta. Se establecieron las normas de trabajo para la extracción de documentos dos años después de concluida la hospitalización del paciente. A partir de enero del año 2000 el hospital "Hermanos Ameijeiras" sustituyó la hoja de egreso por el Informe de Alta y lo incluyó en el proyecto de automatización del departamento de registros médicos del hospital. Después de ocho años de la implantación del Informe de Alta, con un doble propósito: eliminación de documentos de la historia clínica y ser registro básico para obtener información de calidad para la toma de decisiones, se realizó una evaluación que rindió buenos resultados que se presentan en este trabajo.
The need of keeping higher number of medical histories in some premises for archiving and of locating as fast as possible the valuable information on previous stays at hospital if needed, prompted the carrying out of a study to solve this difficulty, which recommended to replace the present discharge form by another custom-designed formulary called Hospital discharge report. The working standards to draw documents out two years after the patient hospitalization were set. From January 2000 on, "Hermanos Ameijeiras" hospital replaced the discharge form by the Discharge Report and included it in the automation project of the medical history department. After eight years of Discharge Report implementation with two objectives: elimination of documents from the medical histories and creation of a basic register to get quality information for decision-making, the evaluation presented in this paper yielded good results.
Subject(s)
Humans , Archives , Efficiency , Medical Records , Patient DischargeABSTRACT
La necesidad de incluir un mayor número de historias clínicas en el local asignado para archivo y localizar en estos con mayor rapidez la información de valor que se desea de hospitalizaciones anteriores, propició un estudio encaminado a resolver esta dificultad, el que recomendó sustituir la hoja de egreso vigente, por otro formulario diseñado expresamente, denominado Informe de Alta. Se establecieron las normas de trabajo para la extracción de documentos dos años después de concluida la hospitalización del paciente. A partir de enero del año 2000 el hospital Hermanos Ameijeiras sustituyó la hoja de egreso por el Informe de Alta y lo incluyó en el proyecto de automatización del departamento de registros médicos del hospital. Después de ocho años de la implantación del Informe de Alta, con un doble propósito: eliminación de documentos de la historia clínica y ser registro básico para obtener información de calidad para la toma de decisiones, se realizó una evaluación que rindió buenos resultados que se presentan en este trabajo(AU)
The need of keeping higher number of medical histories in some premises for archiving and of locating as fast as possible the valuable information on previous stays at hospital if needed, prompted the carrying out of a study to solve this difficulty, which recommended to replace the present discharge form by another custom-designed formulary called Hospital discharge report. The working standards to draw documents out two years after the patient hospitalization were set. From January 2000 on, Hermanos Ameijeiras hospital replaced the discharge form by the Discharge Report and included it in the automation project of the medical history department. After eight years of Discharge Report implementation with two objectives: elimination of documents from the medical histories and creation of a basic register to get quality information for decision-making, the evaluation presented in this paper yielded good results(AU)
