title: Overview of shorthand medical glossary (OMG) study.
abstract: BACKGROUND
  Shorthand is commonplace in clinical notation. While many abbreviations are standard and widely accepted, an increasing number are non-standard and/or unrecognisable.
  
  
  OBJECTIVE
  We sought to describe the frequency of inappropriate and ambiguous shorthand in discharge summaries.
  
  
  METHODS
  Eighty electronic discharge summaries from the four General Medical Units at the Royal Melbourne Hospital were randomly extracted from the hospital's electronic records. Extraction was stratified by the four units and by the four quarters between July 2012 and June 2013. All abbreviations were assigned into one of four categories according to appropriateness: 1. 'Universally accepted and understood even without context'; 2. 'Understood when in context'; 3. 'Understood but inappropriate and/or ambiguous'; and 4. 'Unknown'. These categories were determined by the authors, which included junior and senior medical staff.
  
  
  RESULTS
  The 80 discharge summaries contained 840 different abbreviations used on 6269 occasions. Of all words, 20.1% were abbreviations. Of the 6269 occasions of shorthand, 6.8% were categorised as 'Understood but inappropriate and/or ambiguous' or 'Unknown' (category 3 or 4), equating to 1.4% of all words, and an average of 5.4 words per discharge summary.
  
  
  CONCLUSIONS
  Abbreviations are common in electronic discharge summaries, occurring at a frequency of one in five words. While the majority of shorthand used seems to be appropriate, the use of inappropriate, ambiguous or unknown shorthand is still frequent. This has implications for safe and effective patient care and highlights the need for better awareness and education regarding use of shorthand in clinical notation.
authors.affiliation: The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Politis
authors.forename: S
authors.initials: S
authors.lastname: Lau
authors.forename: J
authors.initials: J
authors.lastname: Yeoh
authors.forename: C
authors.initials: C
authors.lastname: Brand
authors.forename: D
authors.initials: D
authors.lastname: Russell
authors.forename: D
authors.initials: D
authors.lastname: Liew
mesh_terms: D057286:Electronic Health Records / Q000592:standards* / Q000639:trends; D006801:Humans; D010351:Patient Discharge / Q000592:standards* / Q000639:trends; D012781:Shorthand
keywords: communication; internal medicine; patient care; patient discharge; shorthand