Cargando…

Audit of electronic operative documentation in interventional radiology: the value of standardised proformas

BACKGROUND: 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 document...

Descripción completa

Detalles Bibliográficos
Autores principales: Theodoulou, Iakovos, Judd, Rhys, Raja, U., Karunanithy, N., Sabharwal, Tarun, Gangi, Afshin, Diamantopoulos, Athanasios
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Springer International Publishing 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511488/
https://www.ncbi.nlm.nih.gov/pubmed/32965530
http://dx.doi.org/10.1186/s42155-020-00163-w
_version_ 1783585964874006528
author Theodoulou, Iakovos
Judd, Rhys
Raja, U.
Karunanithy, N.
Sabharwal, Tarun
Gangi, Afshin
Diamantopoulos, Athanasios
author_facet Theodoulou, Iakovos
Judd, Rhys
Raja, U.
Karunanithy, N.
Sabharwal, Tarun
Gangi, Afshin
Diamantopoulos, Athanasios
author_sort Theodoulou, Iakovos
collection PubMed
description BACKGROUND: 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 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. RESULTS: The 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. CONCLUSION: The construction of a procedure-specific perioperative electronic proforma can save clinicians valuable time and encourage safe and effective clinical documentation.
format Online
Article
Text
id pubmed-7511488
institution National Center for Biotechnology Information
language English
publishDate 2020
publisher Springer International Publishing
record_format MEDLINE/PubMed
spelling pubmed-75114882020-10-08 Audit of electronic operative documentation in interventional radiology: the value of standardised proformas Theodoulou, Iakovos Judd, Rhys Raja, U. Karunanithy, N. Sabharwal, Tarun Gangi, Afshin Diamantopoulos, Athanasios CVIR Endovasc Original Article BACKGROUND: 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 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. RESULTS: The 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. CONCLUSION: The construction of a procedure-specific perioperative electronic proforma can save clinicians valuable time and encourage safe and effective clinical documentation. Springer International Publishing 2020-09-23 /pmc/articles/PMC7511488/ /pubmed/32965530 http://dx.doi.org/10.1186/s42155-020-00163-w Text en © The Author(s) 2020 Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
spellingShingle Original Article
Theodoulou, Iakovos
Judd, Rhys
Raja, U.
Karunanithy, N.
Sabharwal, Tarun
Gangi, Afshin
Diamantopoulos, Athanasios
Audit of electronic operative documentation in interventional radiology: the value of standardised proformas
title Audit of electronic operative documentation in interventional radiology: the value of standardised proformas
title_full Audit of electronic operative documentation in interventional radiology: the value of standardised proformas
title_fullStr Audit of electronic operative documentation in interventional radiology: the value of standardised proformas
title_full_unstemmed Audit of electronic operative documentation in interventional radiology: the value of standardised proformas
title_short Audit of electronic operative documentation in interventional radiology: the value of standardised proformas
title_sort audit of electronic operative documentation in interventional radiology: the value of standardised proformas
topic Original Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511488/
https://www.ncbi.nlm.nih.gov/pubmed/32965530
http://dx.doi.org/10.1186/s42155-020-00163-w
work_keys_str_mv AT theodoulouiakovos auditofelectronicoperativedocumentationininterventionalradiologythevalueofstandardisedproformas
AT juddrhys auditofelectronicoperativedocumentationininterventionalradiologythevalueofstandardisedproformas
AT rajau auditofelectronicoperativedocumentationininterventionalradiologythevalueofstandardisedproformas
AT karunanithyn auditofelectronicoperativedocumentationininterventionalradiologythevalueofstandardisedproformas
AT sabharwaltarun auditofelectronicoperativedocumentationininterventionalradiologythevalueofstandardisedproformas
AT gangiafshin auditofelectronicoperativedocumentationininterventionalradiologythevalueofstandardisedproformas
AT diamantopoulosathanasios auditofelectronicoperativedocumentationininterventionalradiologythevalueofstandardisedproformas