Home  /  Rev Rene  /  Vol: 17 Núm: 2 Par: 0 (2016)  /  Article
ARTICLE
TITLE

Use of abbreviations in the nursing records of a teaching hospital

SUMMARY

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.

 Articles related

Vivi Silvia,Rokiah Kusumapradja,Idrus Jus'at    

Patient safety has become a global issue in the field of health service including hospital. Implementation of patient safety in the hospital requires the involvement of leadership, effective communication and patient’s trust. At X Hospital Jakarta, the r... see more


Veronica Dzomeku, Brian Van Wyk, Lucia Knight, Jody R. Lori    

It is well established that clients’ past healthcare experiences influence their further use of that particular service, as well as their recommendations of that service. This also applies to the use of facility-based childbirth services which contribu... see more


Penny D Martin, F M Daniels    

The mental health care environment is a stressful nursing environment. The purpose of the study was to develop a model of emotional support for student nurses working in the mental health care environment. The objectives were set in two phases: Phase one... see more


Avie Rotsen Badua,Krystelle Joy Caraquel,Marjorie Cruz,Roison Andro Narvaez    

The 2019 Coronavirus Disease (COVID-19) is dubbed as one of the deadliest and worst global pandemics. Many pandemic policies and programs were implemented in different countries across the globe, including the creation of vaccines that would enhance huma... see more

Revista: Health Notions

Susanto .,Rikhlatul Iffah    

The Islamic Hospital PKU Muhammadiyah Pekajangan is a type C private hospital that is growing in Pekalongan. The successful hospital in the future are hospitals that have a competitive power. To win the competition the hospital must provide value and sat... see more