Throughout Jane’s medical records many abbreviations were used from the face sheet to the progress notes. The use of medical abbreviations in health records have numerous benefits and limitations. For example, physicians spend a large amount of time documenting what occurred during the day. By using abbreviations in medical records, physicians can save time, which allows them to complete other tasks. It can also help minimize spelling errors. However, the limitations of abbreviations exceed the benefits. Medical abbreviations can have multiple meanings in the different fields of medicine. This could cause confusion and lead to clinical errors. This creates poor communication with the staff and could cause more health problems for the patient or even death.
The abbreviations support Jane’s treatment and diagnosis since the medical professionals can document the amount of dosage given for medication. In Jane’s medical record, a variety of abbreviations is used to state what type of treatment she is receiving. For instance, physical and occupational therapy were provided
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For instance, the abbreviation for daily (QD) could be mixed up with the abbreviation for four times a day (QID). When it is capitalized, when someone could misread either abbreviation and the patient would be getting the incorrect dosage. Furthermore, when the nurse typed the x-ray report for the radiologist, s/he could have typos if the report was typed quickly and was not reanalyzed for errors. Anyone who reads that report with typos could mistaken the typo for something else. The consequences of an abbreviation mistake in Jane’s record varies depending on the severity of the mistake. Medical professionals are liable for malpractice and could face consequences such as a lawsuit against them or being fired. These errors can be minimized by being more