News: Avoiding abbreviations increases patient understanding of health records, study shows

CDI Strategies - Volume 16, Issue 21

A new study published in the Journal of the American Medical Association (JAMA) Open Network found that patients’ overall comprehension scores were significantly greater when the medical record documentation used minimal abbreviations.

The study, which was conducted between February 2020 and August 2021, included 60 English-speaking adult patients of three United States-based hospitals with diagnosed heart failure. The participants were divided into two groups: one that reviewed medical documentation with abbreviations and one that reviewed medical documentation without abbreviations. The abbreviations and expansions included:

  • hrs (hours)
  • MD (medical doctor)
  • BP (blood pressure)
  • ED (emergency department)
  • yo (Year old)
  • pt (patient)
  • HF (heart failure)
  • hx (history)
  • HTN (hypertension)
  • MI (myocardial infarction)

When the 10 medical abbreviations were expanded (meaning the term was spelled out instead of abbreviated), the study found that patients’ comprehension increased from 62% to 95%. Even patients with significant prior exposure to the healthcare system had low comprehension of “common” abbreviations such as “HTN” and “MI” (below 40%).

Medical documentation has traditionally been seen as a means of communication between clinicians and a way to capture patient population statistics, appropriate revenue, and quality care metrics. With the advent of EHRs and patient portals, however, the volume of patients who routinely view their health records online has increased significantly. According to the researchers, an estimated 100 million United States residents accessed their medical records online in 2020 alone.

Additionally, the 21st Century Cures Act mandated that EHRs be made more freely accessible, meaning even more patients will be accessing their records regularly. Increasing patients’ understanding of their medical records should go along with this increased accessibility, according to researchers.

“These findings suggest that post hoc or automated expansion of medical abbreviations and acronyms can improve patient understanding of their health information, and may benefit ongoing national efforts to provide patients with electronic access to their own documentation,” they wrote. “Clinicians should be mindful that patient comprehension of abbreviations may be much lower than expected.”

Editor’s note: To read the full study in JAMA, click here. To read more about the 21st Century Cures Act, click here.

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