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A descriptive study of the knowledge of nurses and doctors of clinical abbreviations in hospital discharge reports

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 17.10 s (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.

Otras publicaciones de la misma revista o congreso con autores/as de la Universidad de Cantabria

 Fuente: Enfermería Clínica (English Edition) Volume 29, Issue 5, September-October 2019, Pages 302-307

Editorial: Doyma

 Año de publicación: 2019

Nº de páginas: 6

Tipo de publicación: Artículo de Revista

 DOI: 10.1016/j.enfcle.2019.02.002

ISSN: 1130-8621,1579-2013

Url de la publicación: https://doi.org/10.1016/j.enfcle.2019.02.002