Use of abbreviations in the nursing records of a teaching hospital

Authors

  • Sylvia Miranda Carneiro
    • Herica Silva Dutra
      • Fernanda Mazzoni da Costa
        • Simone Emerich Mendes
          • Cristina Arreguy-Sena

            DOI:

            https://doi.org/10.15253/2175-6783.2016000200008

            Keywords:

            Nursing Records, Abbreviations, Health Communication, Nursing, Team.

            Abstract

            Objective: to evaluate the use of abbreviations in nursing records of a teaching hospital and describing their profile in different sectors, work shifts and professional nursing categories.Methods: documentary study that analyzed 627 nursing records in 24 patient charts using a systematic observation script. Results: we identified 1,792 abbreviations, and 35.8% were nonstandard. The incidence of abbreviations was higher in the Intensive Care Unit, used by nurses and in the night shift. Conclusion: abbreviations are part of the day-to-day of nursing records. The use of nonstandard abbreviations make difficult to understand the note content, can generate misinterpretations, put at risk the users’ safety and impair the continuity of labor work.

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            Published

            2016-04-30

            Issue

            Vol. 17 No. 2 (2016)

            Section

            Research Article

            How to Cite

            1.
            Carneiro SM, Dutra HS, Costa FM da, Mendes SE, Arreguy-Sena C. Use of abbreviations in the nursing records of a teaching hospital. Rev Rene [Internet]. 2016 Apr. 30 [cited 2026 May 26];17(2):208-16. Available from: https://periodicos.ufc.br/rene/article/view/3000