Abbreviations
When in doubt, write it out – in full
Abbreviations are commonly used in clinical records but can be misinterpreted and lead to mistakes in diagnosis or management. So the rule is, when in doubt, write it out – in full. Be aware, too, that patients may, if they access their notes, misinterpret innocuous abbreviations such as SOB (shortness of breath), which most lay people would interpret as an insulting reference to their origins.
Sarcastic and derogatory abbreviations have no place in clinical records – NFN (Normal for Norfolk), FAS (Fat and Stupid) are gratuitously offensive and sure to destroy any therapeutic relationship once found out.
Case 3
A 38-year-old woman phoned her GP surgery complaining of back pain and difficulty passing urine. The GP checked her notes and saw a reference to PID, which he interpreted as pelvic inflammatory disease. He concluded that she had another urinary tract infection and wrote a prescription for antibiotics for the patient to collect. In fact PID referred to her recurring problems with a prolapsed intervertebral disc which had now given rise to a cauda equina syndrome and associated pain and urinary symptoms.