Use of Abbreviations in Ophthalmic Medical Record
Narrative Responses:
Purpose
Communication between specialties is vital for effective patient care. Primary care providers (PCPs) direct outpatient care and note that specialty-specific abbreviations are hard to understand. Ophthalmologists use many abbreviations in clinical notes, thus we reviewed our records and surveyed PCPs on which abbreviations they understand.
Methods
We reviewed 500 ophthalmology clinic charts and compiled a list of abbreviations used. We sent these abbreviations in a survey to all PCPs in our health system to determine which abbreviations they could understand. The survey also asked basic demographic questions, such as how many years in practice and which branch of primary care, and if the PCP has any suggestions for improvement in our documentation in the medical record.
Results
Eighty-nine distinct abbreviations were found in our notes, and 90.4% of notes contained an abbreviation in the assessment and/or plan. Nineteen abbreviations were found in at least 5% of notes. For the survey, 19 of 40 PCPs responded. Eighteen of the 19 PCPs said they have looked at an eye note in the past and not understood part or all of the assessment and/or plan. Only the abbreviations OD, OS, OU, and IOP were understood by more than half of the PCPs. All other abbreviations were poorly understood, if at all.
Conclusion
Almost all eye notes contain abbreviations and are not understood by PCPs. Electronic records allow for “Smartphrases”, so each eye MD could have a Smartphrase in his/her note. PCPs recommended that either no abbreviations be used in the assessment/plan or a key be given.