Hey there 2017 interns!
Welcome to doctor-hood.
You may be the most junior member of the team, but you’ll quickly become the go-to guy or gal for that sacred document – the discharge summary.
Abbreviations are pervasive in medicine. Yes, they can save a few seconds here and there, but the discharge summary is not the place for them to be used and abused.
Take the following:
Mrs. P, 70 yo F presented to ED with CP. She was admitted under cardio for Ix and Mx.
- L TKR
- ORIF # R NOF
- STEMI – Rx DAPT, PCI with DES to LCx. Statin, ACEi and B-blocker commenced.
- AKI on CKD – IVF
- Cont. DAPT 12/12
- F/U Cardio 6/52
- GP F/U CKD
GP F/U CKD indeed.
Does she have mitral stenosis or multiple sclerosis?
Surely ORIF is a gimmie though.
Maybe for you hospital doctors. ORIF was incorrectly interpreted by 28% of GPs surveyed in the Blue Mountains area (1).
Also, it’s not just the GP that you are writing to. How is a garbled collection of letters going to help our patient?
Often, the section that matters most to our patients is the discharge medication list.
Let’s say your patient gets home, has had 4 new medications initiated and can’t remember exactly how much of that pill to take, so they pull out that top-notch discharge summary you have composed only to find:
Apixaban 5mg PO BD
Your patient is not the Latin scholar that you thought she was when you were writing this down, and she struggles to decipher BD and PO.
Now she’s at harm of bleeding if she’s overdoes it, or clotting if she underdoes it.
Are the seconds that you save using the twice per day and per oral shorthand really worth it?
I’m not saying you need to write endoscopic retrograde cholangio-pancreatography 12 times in the summary. Just define it in your first usage and then go nuts. The medication list, however, is non-negotiable.
I envisage an electronic system where there is an autofill function, whereby typing TTE will autocorrect to transthoracic echocardiogram, or give you a pop-up option where use abbreviations like MS where more than one option exist. Let me know if this is already happening in your networks.
Above all, use the grandma test. Think of your own grandma when you’re writing the summary, and ask whether or not the information you are including would be useful to her if she were the patient.
And again, a hearty welcome to your internship. It is the best of times, it is the worst of times, but you have toiled to become the highly skilled individual you are, so enjoy it.
You only intern once.
(1) Chemali M, Hibbert EJ, Sheen A. General practitioner understanding of abbreviations used in hospital discharge letters. Med J Aust. 2015;203(3):147, e 1-4.