[Abbreviations or acronyms in the internal medicine discharge reports. Study Group of the Quality of Information in Internal Medicine (Castilla-La Mancha)].
OBJECTIVE
Quality of discharge reports is very important for an adequate health care activity. Clinical data of these reports must be comprehensible by patients and in the different levels of Health Services. Presence of abbreviations causes severe shortcomings in the clinical data of these records.


METHODS
We analyzed the presence of abbreviations in the Internal Medicine discharge reports of 7 hospitals of Castilla-La Mancha in the year 1992. We evaluated 835 discharge reports.


RESULTS
Abbreviations were found in personal background 72.4%, present disease 31%, physical examination 87.2%, clinical judgement 39.4%, complementary explorations 95.8%, evolution 61.4% and treatment-follow up after discharge 67.4%.


CONCLUSIONS
These results indicate that abbreviations must be avoided in discharge reports in order to obtain a better communication between patient and doctor and between medical personnel.
Viana Alonso
A
A
Departamento de Medicina Interna, Hospital Universitario de Guadalajara, Universidad de Alcalá de Henares, Madrid.
de la Morena Fernández
J
J
D007388:Internal Medicine / Q000592:standards; D008499:Medical Records / Q000592:standards; D010351:Patient Discharge / Q000592:standards; D011786:Quality Control; D013030:Spain; D009626:Terminology as Topic
Abreviaturas o siglas en los informes de alta en medicina interna. Grupo de Estudio de la Calidad de Los Informes de Alta en Medicina Interna (Castilla-La Mancha).