非放射科医师放射检查结果的文件记录。审核

Terence Jones, Matthew Booker, Stephanie Hobbins, Dee Dawkins
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引用次数: 1

摘要

目的评估转诊医疗团队是否在临床记录中记录了影像学表现。所有x线片应由转诊医疗小组检查,并记录在临床记录中。样本:英国伯明翰城市医院的所有成年住院患者。设计前瞻性医疗记录现场审计。方法采用PACS(图片存档与通讯系统)确定住院期间拍摄的x线平片。这与病人的记录相一致,以确定转诊医疗小组是否记录了这些发现,以及记录这些发现的延迟。基线审计于2007年9月进行,并于2008年8月重新审计。发表了一封强调记录调查结果重要性的信。贴纸贴在临床记录上,作为对转诊医疗队的提醒。结果基线审计我们评估了164名成年住院患者的388张x线片。147例(37.9%)没有接受转诊医疗队检查的证据。在记录的241张x线片中,230张(95.8%)在拍摄后2天内记录。在2008年8月的重新审核中,我们评估了279名成年住院患者的687张x线片。记录了492张x线片,其中467张(94.9%)在2天内报告。无证x线照片的绝对减少比例为9.6%,这代表了25%的改善(p <0.002)。结论:本次审核表明,许多住院患者的x线片没有被转诊医疗小组检查或采取行动的临床记录证据。在医疗记录上贴上提醒标签可以提高报告率。
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Documentation of radiographic findings by non-radiologists – An audit

Purpose

To assess whether radiographic findings were documented in the clinical notes by the referring medical team.

Standard

All radiographs should be checked by the referring medical team, and documented in the clinical records.

Sample

All adult inpatients at City Hospital Birmingham, UK.

Design

Prospective spot audit of medical records.

Method

We established which plain radiographs had been performed during that admission using PACS (picture archiving and communication system). This was reconciled against the patients' notes to determine if findings were documented by the referring medical team, and the delay in documenting their findings. A baseline audit was performed in September 2007, and re-audited in August 2008.

Intervention

A letter highlighting the importance of documenting findings was circulated. Stickers were affixed to clinical notes to act as a reminder for the referring medical team.

Results

For the baseline audit we assessed 388 radiographs of 164 adult inpatients. 147 (37.9%) showed no evidence of being checked by the referring medical team. Of the 241 radiographs which were documented, 230 (95.8%) were documented within 2 days of being performed.

For the re-audit in August 2008, we assessed 687 radiographs of 279 adult inpatients. 492 radiographs were documented, of which 467 (94.9%) were reported within 2 days. The absolute reduction in the proportion of undocumented radiographs was 9.6% which represents a 25% improvement (p < 0.002).

Conclusion

This audit demonstrates that many inpatient radiographs have no evidence documented in clinical notes of being checked or acted upon by the referring medical teams. Affixing a reminder sticker to medical notes improves reporting rates.

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