Abstract
BackgroundOn the background of the interventional radiology department of a tertiary hospital converting its periprocedural documentation from paper-based to electronic using a standardised proforma, a study was performed to ascertain the effects of this change on the standard of clinical documentation for radiologically-guided angiographic procedures. Using a retrospective approach, perioperative records were analysed in reverse chronological order for inclusion in the study. The standard for this audit was developed in the form of minimum criteria that all clinical documentation of angiographic procedures were expected to meet.ResultsThe audit was performed at three equally spaced intervals of 6 months, yielding a total of 99 records. The baseline audit of paper-based records concluded > 80% completeness for 8 out of the 14 of parameters measured, with only two of parameters meeting the target of 100% completeness. The second audit cycle performed on electronic records found 7 out of 14 parameters demonstrating absolute improvement in completeness, when compared to paper-based, but with the number of parameters exceeding 80% completeness falling to only 4 out of 14. Again, 100% completeness was observed in only 2 of the parameters. In the final audit cycle, after the introduction of a standardised electronic proforma, performance improved in every dimension with 6 out of 14 parameters reaching completeness of 100% and the 80% completeness threshold met by 12 out of 14 parameters.ConclusionThe construction of a procedure-specific perioperative electronic proforma can save clinicians valuable time and encourage safe and effective clinical documentation.
Highlights
On the background of the interventional radiology department of a tertiary hospital converting its periprocedural documentation from paper-based to electronic using a standardised proforma, a study was performed to ascertain the effects of this change on the standard of clinical documentation for radiologicallyguided angiographic procedures
Effective communication is of paramount importance in healthcare service provision, with accurate clinical documentation forming the foundation of safe, transparent and auditable clinical practice
Interventional radiology (IR) has seen a significant expansion in its scope and complexity of practice. This has led to a gradual shift in responsibility from service provision for other clinical specialities to interventional radiology (IR) taking ownership of the peri and postoperative care for patients treated
Summary
Interventional radiology (IR) has seen a significant expansion in its scope and complexity of practice This has led to a gradual shift in responsibility from service provision for other clinical specialities to IR taking ownership of the peri and postoperative care for patients treated. Coupled with the rapidly increasing number of image-guided interventions available, it follows that appropriate documentation of periprocedural care is fundamental both for successful patient-centred care and support for the autonomy of IR as a specialty (Kohi et al 2015) This is in line with requirements as set out by the Joint Commission on the Accreditation of Healthcare Organizations (Novitsky et al 2005)
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