OBJECTIVES:To (1) compare abbreviation usage practices in the Doctors' Orders and History Sheet in two tertiary hospitals in Cebu City, namely, Cebu Velez General Hospital (CVGH) and Vicente Sotto Memorial Medical Center (VSMMC); (2) determine why medical students and physicians use abbreviations and (3) determine the perceived effects on medical student training.
METHODS:This is a descriptive cross-sectional study utilizing medical chart reviews as well as group and key informant interviews. Stratified Random Sampling with Proportionate Allocation was used to select 100 charts each from CVGH and VSMMC. Purposive sampling was done for key informants.
RESULTS: All patients' clinical history, physical examination and doctors' orders in all departments of both hospitals contained abbreviations. First initialization was the most common form, e.g. BP (blood pressure). Non-universally-accepted abbreviations were common, e.g. HFD (heredofamilial disease). Potentially dangerous abbreviations were noted, e.g. d/c, D/C. Abbreviations were used to maintain patient-doctor confidentiality, save space and time, and for convenience. Perceived effects on medical training included speeding up of task performance.
CONCLUSIONS: Use of abbreviations in medical charts among medical students and physicians in both private and public tertiary hospitals in the Philippines is a prevalent practice. While such has its perceived benefits, it also poses potential danger to patients because not all abbreviations are understood and used the same way. Medical schools and their training hospitals must initiate moves to standardize the use of abbreviations in medical education and promote awareness of their potential dangers. The authors suggest that potential dangers/benefits of abbreviations be formally introduced in medical school as a separate topic.