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Errors in medication and documentation are reported.1,2 These errors, no matter how minor, could have grave consequences for the patient, especially in the paediatric population. One can imagine the potential threat to small neonates. Recently, Carroll et al3 described problems in residents’ progress notes in a neonatal intensive care unit. Being the busiest centre in the country, managing the great majority of seriously sick neonates, we are at a very high risk of these errors. In view of this and as a screening audit, we looked at a few progress notes written on our inpatient neonates. One example of a progress note, written by a junior doctor, stated “Prem 32 WOG, F&G, Problems: RDS, IVH II, S/P SVT, Stable on RA, TPR normal, PU, BO. Chest, CVS & abdomen: NAD”. This excessive and inappropriate use of abbreviations is alarming and disturbing. The abbreviations used denoted the following (in order of citation): weeks of gestation, feeder and grower, respiratory distress syndrome, intraventricular grade 2 haemorrhage, status post supraventricular tachycardia, room air, temperature pulse respiration, passed urine, bowel open, cardiovascular system, and no abnormality detected. This prompted us to look further into the use of abbreviations in the daily progress notes in our neonatal unit.
A cross section survey was carried out at the Special Care Baby Unit (SCBU), Royal Hospital, Muscat, on 7 October 2003. Thirty consecutive charts were reviewed. The progress notes written by seven different doctors (three registrars and four resident medical officers) were analysed for use of abbreviations. The commonly used ones were: CP (crystalline penicillin), RR (respiratory rate), HR (heart rate), BP (blood pressure), PA (per abdomen), O/E (on examination), NGT (nasogastric tube), UE1 (urea and electrolyte 1), BGA (blood gas analysis), BBA (born before arrival), TPN (total parenteral nutrition), SLS (standard lipid solution), STS (standard TPN solution), D/w (discussed with), SBR (serum bilirubin), CTG (cardiotocograph), IUGR (intrauterine growth restriction), BT shunt (Blalock-Taussig shunt), TAT (trans-anastomotic tube), IVF (intravenous fluid or in vitro fertilisation), POD (postoperative day), ASD (atrial septum defect), VSD (ventricular septum defect), PDA (patent ductus arteriosus), TR (tricuspid regurgitation), L-R shunt (left to right shunt), TOF (tetralogy of Fallot), CRT (capillary refill time). One interesting note that needs separate mention was “Plan is to start ABs after ABC” (ABs, antibiotics; ABC, aerobic blood culture).
We noted a high frequency of the use of abbreviations in our neonatal unit. This was a single day observation; we would expect much more in a longitudinal study. Fortunately, none of the abbreviations had resulted in erroneous interpretation, as most of the staff were used to them. However, this does not indicate that it is all right to use abbreviations. Standard abbreviations, such as VSD (ventricular septal defect) and PDA (patent ductus arteriosus), are acceptable, whereas others are not.
Documentation errors have been reported to be an increasing problem in day to day care of patients.4,5 A recent report described the same negligence in documentation by residents. Carroll et al3 found discrepancies in the daily progress notes written by a resident doctor in the neonatal intensive care unit. They also found that notes often contained inaccurate information and lacked pertinent information. We looked further into the situation and found extensive use of abbreviations in progress notes.
Our observation is not unique and requires rectification. The solution could be to standardise or eliminate the use of abbreviations in the unit. Total elimination would be difficult, as many of the abbreviations are acceptable. Thus, the use of unacceptable abbreviations should be discouraged. New medical officers should be given brief instruction on the writing of appropriate progress notes. An alternative is to use the electronic information system for all medical transcription including progress notes, as described elsewhere.6,7
In conclusion, care of neonates requires good documentation of day to day progress. The use of unacceptable abbreviations should be discouraged. A follow up audit is warranted to look further into the effect and success of our recommendations.
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