Page 27 - Hospitalists - Risks When You're the Doctor in the House (Part Two)

SVMIC Hospitalists - Risks When You’re the Doctor in the House

2 Use abbreviations with caution

“This is where the issue of context becomes very important,”

he said. Suppose a patient has a rare disease, and you
use an abbreviation for it. “Everybody knows what the

abbreviation means at the time, but three years down the
road, you can actually spend time in a deposition or with

opposing counsel arguing over what that abbreviation
meant,” said Dr. Smith.

In court, abbreviations can even be misinterpreted as
something offensive. “There has been at least one case

I know of where SOB was successfully argued by a
plaintiff to be an insult put into the chart,” he said. Such

a misunderstanding may seem deliberate, but other
abbreviations can be reasonably understood in different

ways. “‘Discussed Dr. So and So.’ This one is actually very
dangerous. Does it mean discuss with or discussed—past

tense—with?” said Dr. Smith. This uncertainty leaves room
for a physician involved in a lawsuit to argue he was never

consulted, he explained.

This doesn’t mean you have to avoid abbreviations entirely,
though. “If you take the approach you see in the medical

literature where every time an abbreviation is used you
actually define it for the first time and then you use the

abbreviation in the rest of the note, then you can copy that
approach and save yourself some time,” he said.

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