Tim Friedlander's presentation on the use of abbreviations in contemporaneous notes. Osteopaths need to be mindful that third parties need to be able to understand notes and not just other osteopaths.

1. Abbreviations in Osteopathic
Case Notes

2. An Example

65 y.o. ♀ w/ R.A. p.w. ® CSp , dull, 6/10 VAS w/
Ø s/m ssx => HA over last 3/7, NAR

OE: C2/3 FRRSL, sp. (L) CESp, (B) UEx ref. ++
Gen. ↓ QOM C1-3 (B), ARMT (L) scalenes +ve

Dx: S.D. C2/3 w/ cervicogenic HA

TTx: ST (B) CESp, subocc. mm, MET C2/3, gen.
CSp artic

3. The Problem


You may understand your notes, but other
people need to understand them as well
This may include:






Other osteopaths
Other health professionals
ACC
External reviewers
Patients
This may, on occasion, be done without
your presence!

4. The Problem

In a study of surgical inpatient admissions,
the average correct identification of
abbreviations was:
43%

Doctors scored highest with an average of
57% correct

Dieticians scored the worst with 20%

Sinha S, McDermott F, Srinivas G & Houghton P. (2011). Use of Abbreviations by
Healthcare Professionals. Postgraduate Medical Journal, 87(1029), 450-452

5. The Problem
“Use of abbreviations is widespread in
medical records and may be a cause of
concern” but “We believe that while it is
impossible to expect healthcare
professionals not to use abbreviations
altogether, their use should be kept to an
absolute minimum for effective and safe
communication in patient care.”

Sinha S, McDermott F, Srinivas G & Houghton P. (2011). Use of Abbreviations by
Healthcare Professionals. Postgraduate Medical Journal, 87(1029), 450-452

6. The Current Situation

Several publications list medical acronyms
and abbreviations


e.g. W.B. Saunders Company. (1992). Dorland’s
Medical Abbreviations. Saunders.
But there is a lack of definitive guidelines to
osteopathic terminology.

Although see Glossary of Osteopathic Terminology,
http://www.aacom.org/people/councils/Pages/ECOP.
aspx

Old version .pdf

7. The Solution?


OCNZ has therefore identified a need to
provide guidance on standardised
abbreviations to ensure clear
communication in written material.
The abbreviations are currently based on:
 Work by Fryer (Fryer, G. (2001). Abbreviations for use in
osteopathic case notes. Journal of Osteopathic Medicine, 4(1), 21-24)

Guidelines produced by the Department of
Osteopathy, Unitec for use in the
programme and student clinic.

8. The Solution?

We are now looking to consult the
profession to complete this guide

It is intended as a reference for common
abbreviations

9. The Solution?

It is not intended to dictate how you
write your notes

It is not intended to list every known
abbreviation, just those common and
specific to osteopathy

10. The Solution?
The document as it currently stands:

11. The Solution?

You can view the document in full on
Huddle

You can contact me with comments,
additions or disagreements at
tim@osteopathiccouncil.org.nz