The problem with abbreviations in the medical record

Several patients seen in our practice recently were significantly and dramatically transformed by the electronic health record (EHR). And not in a good way.

Take, for instance, the patient whose outside chart was reviewed when she showed up in our office for a follow-up appointment after an emergency department visit.

The notes from the emergency department providers, including a scribe and the attending physician, described her in the following way:

“This 67-year-old woman with morphine sulfate presented after a fall with injury to her head.”

Throughout the documentation, they kept referring to her as a patient with morphine sulfate.

For a while, as I read through it, my eyes skimmed over this, and it didn’t really register as something I needed to pay attention to.

Perhaps they were taking note of the fact that she had morphine sulfate with her when she arrived, had taken morphine sulfate before the fall, or was requesting morphine sulfate to ease her pain.

Only after diving deeper into her past medical history in our own chart did I realize that someone must’ve typed “MS,” and the computer auto-corrected and somehow turned that into morphine sulfate, instead of multiple sclerosis.

A menu of choices

I’m not sure how their system works, but most of the functionality of EHRs that has been created to prevent medical confusion from abbreviations offers you a choice of what it thinks you’re looking for, the most obvious or most common diagnoses usually typed by physicians.

So maybe the system saw “MS” and offered up morphine sulfate, multiple sclerosis, mitral stenosis, myasthenic syndrome, magnesium sulfate. Pick one.

Or maybe their system just turned “MS” into morphine sulfate without giving them any choice.

This is what happens in our EHR when we try to type “AS” for aortic stenosis. The only options it gives you are the ones that have to do with ears (AS used by ENT’s for “auris sinistra”, Latin for left ear):

“The patient has a history of {:8051996: “both ears”, “right ear”, “left ear”}.” No matter what you do, the EHR won’t let you leave “AS” there, and it does not offer up aortic stenosis as an option.

As I envision it, our patient in the ER was probably telling the doctors her story, and the scribe was happily typing away, and perhaps they toggled to the wrong choice, or else the system made a choice for them.

But either way, the attending note that agreed with the scribe’s documentation contained the same incorrect and misleading characterization of this patient’s past medical history.

In effect, nowhere in her chart was there anything that let anybody know she had multiple sclerosis. Potentially relevant and clinically important.

And potentially, people may have seen that notation and said, “Oh well, another patient who falls down and comes to the ER looking for opiates.”

The medical documentation community has battled against abbreviations for many years, primarily because of the risk of an abbreviation being used by one person to mean one thing, and interpreted by someone else to mean something different altogether.

Many years ago, when we used the electronic health record more as a word processing document, I remember seeing numerous occasions where a patient with MR (mitral regurgitation) was suddenly “transformed” into a patient with mental retardation. And vice versa.

Abbreviations have always been a challenge in medicine, and we’ve all read charts and seen subspecialists using a string of letters that we have no idea what they are for.

Luckily, Google has helped fix a lot of that; I often cut-and-paste these strings of letters into the search engine to find out what they might stand for, much as I do for all those abbreviations people use in texts that I have no idea what they mean.

IMHOROTFLDGMW.

And in the old days, when we handwrote our medical orders, there were often incredibly dangerous errors that occurred when magnesium sulfate was ordered for a patient and they ended up receiving massive doses of morphine sulfate.

The sleepy patient

I remember once, as an intern, a patient came into clinic for a blood pressure check after he’d been given a medication for hypertension in the emergency room.

His blood pressure hadn’t budged, but he said the pill made him really sleepy.

A copy of the prescription from the emergency room revealed the handwritten scrawled name of the medication, benazepril, but the bottle the patient had picked up in the pharmacy contained Benadryl.

Not very good for high blood pressure, but pretty good for making you pretty sleepy.

Whoever saw our patient with multiple sclerosis in the emergency room last week probably thought they were adding the correct medical terminology for the health condition she had to her chart, but in the end, we were left with documentation that helped us not at all.

Think how some of these things could end up percolating through the record, and potentially leading to harm.

Often, when patients’ charts are dictated by a physician, I’ve seen the following notation added to the end of their consult letters:

“Letter dictated but not read for accuracy to expedite care.”

That scares the heck out of me. In our efforts to speed things up we risk slowing things down, throwing sand into the gears that should move things along.

Keeping things straight

So as much as these little tricks can help make sure we don’t put in confusing abbreviations, perhaps the risk of having the document not end up being the true record of what happened is just too great.

As we work with the people who’ve created these electronic health records, we need to make sure that the cute little shortcuts that they put in don’t cloud the waters of the care we are trying to provide.

Our current electronic health record has lots of these little widgets built in, lots of macros, lots of click boxes that let you instantly fill out an entire review of systems or physical examination without ever getting near a patient, and lots of pre-templated notes that you toggle through and change yes to no, left to right, or better to worse.

There are smart sets and express visits that bundle many of the things we do for single issue care including the history, physical examination, orders, education, and plan, in an effort to streamline our care.

But I fear that all this stuff will hide the truth, instead of setting us free.

No more BS.

Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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