Medical professionals communicate with each other using abbreviations and acronyms.
Abbreviations are used often in the medical field. Nurses making notes on their patients use them to communicate with other nurses. Doctors use them when writing out medical orders or patient histories. Many of the words are simple abbreviations, like "CS" (for cesarean section), and some are abbreviations of old Latin phrases, such as "HS" (for "hora somni" meaning "at bedtime). There are three main reasons abbreviations are helpful and necessary in the medical field, and one reason why they aren't.
They Save Time
Documentation is important in the medical field, and when writing notes about a patient, there can be a lot of information to record. Abbreviations can save time for all medical professionals. For instance, writing "CPAP" is far easier than "continuous positive airway pressure." It saves time for the person making the notes, and the person reading them. Hundreds of abbreviations and acronyms can be used when recording a history for a single patient.
Universal Communication
From a large city hospital to a small country health clinic, the words mean the same thing. "WNL" means "within normal limits" regardless of the person, place or even primary language. Often patients are transferred to other facilities, or may request their records be sent to other practitioners. In these cases, it is helpful to have a form of communication that is universal across the board.
They Maintain Confidentiality
Abbreviations were not invented to maintain confidentiality, but they now help in protecting it. Because many of the abbreviations are confusing to the untrained eye, unauthorized viewers may not understand what they are reading even if they happen to catch a glimpse of another patient's notes. This is particularly important since the initiation of HIPAA (Health Insurance Portability and Accountability Act).
An Increase In Errors
Unfortunately, though abbreviations may benefit health care workers by saving time as well as money, there are some abbreviations that have caused serious medical errors.
Certain abbreviations, such as writing "u" for "unit" and "cc" for "cubic centimeters," can be mistaken for other medical abbreviations. "U" may look like a zero at the end of a number, leading to a serious medication error. It may also appear as "IV" or "intravenous," causing the medication to be given via the wrong method. This and other dangerous abbreviations have been "blacklisted" by the Institute for Safe Medication Practices' Medication Error Reporting Program (MERP). Unfortunately, many nurses and physicians have been using them for so long that they find their old habits hard to break. Some facilities have penalties for using these abbreviations, while others do not address the issue until there is a problem.
Tags: medical field, abbreviations acronyms, communicate with, have been, making notes
