Using Abbreviations in your MedARKS Records:

BAR, CTM, ADR, kpr, D/C, QAR, FB, NPS, OS, QNS, mm pi

How many of the above abbreviations do you recognize? All were extracted from MedARKS records contributed by a number of institutions from across the U.S.A. How many do you think are universal enough that a colleague in Europe or Australia would also recognize and understand these entries in a medical record?

Like many of the sciences, veterinary medicine has developed a specialty language that abounds with acronyms and abbreviations. Some of these abbreviations, derived from Latin origins or carried over from the human medical field, are virtually universal and can be safely used within veterinary medical records (e.g., b.i.d., p.o., s.i.d.). Other acronyms (e.g., ADR) are much more regional and may be unfamiliar to someone working even in a different part of the same country. Most abbreviations or acronyms were developed to save time when writing paper records and have carried over, almost as a habit, when we switched to computerized records. In an age when a record search meant that you opened a file cabinet drawer and read every record to locate those that were of interest, the use of abbreviations made no difference to this process. However, with automated text searches possible in a computerized record system, the use of abbreviations may complicate the planning or execution of an automated search. Abbreviations that are universally understood in veterinary medicine are acceptable in computerized records and abbreviations may be required in some parts of a computerized record due to space limitations, but otherwise, you should think carefully about the use of any abbreviations within your MedARKS records. MedARKS provides you with a number of tools that allow you to avoid using many abbreviations without sacrificing data entry speed, so the excuse that abbreviations save time is often no longer valid.

1. Improved record retrieval: Searching records for a particular piece of information can be more difficult when the information is present in abbreviated form. Abbreviations may cause unexpected matches in a computerized search. For example, if you are in the habit of using "ADR" in your records, and then decide to search for all records where you have made this entry, you could also retrieve all records containing such words as adrenal, quadriceps, quadrant and Benadryl. Your job of examining those records containing "ADR" has been complicated by the task of discarding the false matches produced by using this particular abbreviation.

The retrieval problem becomes more severe when you use abbreviations inconsistently. Imagine that you want to examine all the records where there was a problem with the left eye. Could you simply search your records for "left eye" or would you need to search for "left eye", "lt eye", "lt. eye", "o.s." and "os"? Clearly, the latter search is more complex to perform and the "os" entry will complicate the results by yielding many false positive matches. Either avoiding abbreviations (always enter "left eye") or always using the proper abbreviation ("o.s.") would make your record search both easier and more productive.

 

2. Sharing information with meaningful content: Abbreviations that make sense within your institution can quickly become useless once that information is shared with another institution (information sharing happens every time you include a diskette of MedARKS records along with an animal being shipped to another institution). As an example, consider just the laboratory information in the clinical pathology (hematology and blood chemistry) records. It is (unfortunately) a common practice to severely abbreviate these entries. Within an institution, the laboratory abbreviated "M.S.D.L." will probably have some meaning, but send that record elsewhere and the next institution is left wondering if that work was done at the "Michigan State Diagnostic Laboratory", the "Minnesota State Diagnostic Laboratory", or somewhere else entirely.

So, now you are convinced that abbreviations should be avoided, but how do you fix the existing records?

BAR = bright, alert and responsive

CTM = continue treatment and medication

ADR = Ain't doing right

kpr = keeper

D/C = discontinue

QAR = quiet, alert and responsive

FB = foreign body

NPS = No parasites seen

OS = left eye

QNS = quantity not sufficient (for analysis)

mm pi = mucous membranes pink

written by J. Andrew Teare, DVM
Last update: 2.Nov.1998