INTRODUCTION: The use of abbreviations in patient records in Danish hospitals is extensive. The purpose of this study was to investigate the use of abbreviations, how they affect the comprehension, and how much time was saved writing abbreviations.
METHODS: The study consisted of four sub-studies. First, a prospective collection of abbreviations from patient records. From these, three sentences were constructed and used in the other three sub-studies: a questionnaire for doctors concerning the use of abbreviations, an evaluation of time used to understand abbreviated versus non-abbreviated sentences, and a theoretical analysis of time saved by reducing the number of written characters.
RESULTS: We found several abbreviations with multiple meanings. Writing a sentence with abbreviations saved 20 seconds. Comprehension of an abbreviated sentence took an extra 12-85 seconds. There was no difference in comprehension of abbreviations based on medical experience. Finally, data showed that neurologists' self-rated comprehension of complicated abbreviated sentences was very good.
DISCUSSION: Numerous abbreviations were used in Danish patient records, many which could not be looked up. The use of abbreviations in patient records might not live up to the Danish record-keeping order, and we proposed four solutions to overcome the problem: more bureaucracy and administration; embrace and expand use of abbreviations; introduction of artificial intelligence to interpret abbreviations; or usage of speech recognition software in all Danish hospitals.
TRIAL REGISTRATION: none.
|Bidragets oversatte titel||Not Available|
|Tidsskrift||Ugeskrift for Laeger|
|Status||Udgivet - 12 dec. 2022|