Background Our Caldicott Guardian noticed through management of subject access requests (SARs) that on occasion notes may lack objectivity, resulting in the redaction of notes that may otherwise have caused undue distress on behalf of the reader. Our team is made up of multiple different professionals who use a variety of abbreviations, this can lead to confusion which may affect the quality of communication and team working between colleagues. Ultimately this can affect patient care and safety. We wanted to determine whether this was a consistent theme within our organisation.

Aims

1. To assess if documentation is objective and without jargon.

2. To examine the use of abbreviations and create an organisational glossary of acceptable abbreviations.

Methods 10 sets of notes from the in-patient unit and 10 from the community team were reviewed. Entries were scrutinised for objectivity, jargon and abbreviations. Any clinical documentation made by the case note reviewer was cross-checked by another reviewer to reduce bias as far as possible. All abbreviations were noted and used to develop an agreed specialist palliative care glossary that can be used by clinical staff in the organisation when documenting.

Results While full audit results are yet to be analysed, initial results suggest that abbreviations are commonplace and not universally understood by our workforce. Subjectivity is more likely to arise when documenting under pressure outside of direct clinical consultation, such as during multidisciplinary meetings.

Conclusions SARs are becoming more frequent in our organisation. Staff should be mindful that all documentation may be read by patients or family members. As digital abbreviations become more common in society, clinical teams need to agree upon accepted terms to ensure all language used is accessible to healthcare professional and the public alike.