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- Title
Use of abbreviations in the nursing records of a teaching hospital.
- Authors
Miranda Carneiro, Sylvia; Silva Dutra, Herica; Mazzoni da Costa, Fernanda; Mendes, Simone Emerich; Arreguy-Sena, Cristina
- Abstract
Objective: to evaluate the use of abbreviations in nursing records of a teaching hospital and describe 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 records content, can generate misinterpretations, put at risk the users’ safety and impair the continuity of labor work.
- Subjects
BRAZIL; ABBREVIATIONS; ACADEMIC medical centers; INTENSIVE care units; NURSING records; NURSING services; SHIFT systems
- Publication
Rev Rene, 2016, Vol 17, Issue 2, p208
- ISSN
1517-3852
- Publication type
Article
- DOI
10.15253/2175-6783.2016000200008