Use of abbreviations in the nursing records of a teaching hospital

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 observatio...

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Main Authors: Sylvia Miranda Carneiro, Herica Silva Dutra, Fernanda Mazzoni da Costa, Simone Emerich Mendes, Cristina Arreguy-Sena
Format: Article
Language:English
Published: Universidade Federal do Ceará 2016-04-01
Series:Rev Rene
Subjects:
Online Access:https://www.periodicos.ufc.br/rene/article/view/3000
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author Sylvia Miranda Carneiro
Herica Silva Dutra
Fernanda Mazzoni da Costa
Simone Emerich Mendes
Cristina Arreguy-Sena
author_facet Sylvia Miranda Carneiro
Herica Silva Dutra
Fernanda Mazzoni da Costa
Simone Emerich Mendes
Cristina Arreguy-Sena
author_sort Sylvia Miranda Carneiro
collection DOAJ
description 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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institution Kabale University
issn 1517-3852
2175-6783
language English
publishDate 2016-04-01
publisher Universidade Federal do Ceará
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series Rev Rene
spelling doaj-art-24bf3f9ccf894a42ba7c4f662dd145522025-08-24T12:50:51ZengUniversidade Federal do CearáRev Rene1517-38522175-67832016-04-01172Use of abbreviations in the nursing records of a teaching hospitalSylvia Miranda CarneiroHerica Silva DutraFernanda Mazzoni da CostaSimone Emerich MendesCristina Arreguy-SenaObjective: 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.https://www.periodicos.ufc.br/rene/article/view/3000Nursing RecordsAbbreviationsHealth CommunicationNursingTeam.
spellingShingle Sylvia Miranda Carneiro
Herica Silva Dutra
Fernanda Mazzoni da Costa
Simone Emerich Mendes
Cristina Arreguy-Sena
Use of abbreviations in the nursing records of a teaching hospital
Rev Rene
Nursing Records
Abbreviations
Health Communication
Nursing
Team.
title Use of abbreviations in the nursing records of a teaching hospital
title_full Use of abbreviations in the nursing records of a teaching hospital
title_fullStr Use of abbreviations in the nursing records of a teaching hospital
title_full_unstemmed Use of abbreviations in the nursing records of a teaching hospital
title_short Use of abbreviations in the nursing records of a teaching hospital
title_sort use of abbreviations in the nursing records of a teaching hospital
topic Nursing Records
Abbreviations
Health Communication
Nursing
Team.
url https://www.periodicos.ufc.br/rene/article/view/3000
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