Abbreviations in Osteopathic

Case Notes

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

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!

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

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

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

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.

The Solution?

We are now looking to consult the

profession to complete this guide

It is intended as a reference for common

abbreviations

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

The Solution?

The document as it currently stands:

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