Theodoulou Iakovos, Judd Rhys, Raja U, Karunanithy N, Sabharwal Tarun, Gangi Afshin, Diamantopoulos Athanasios
Department of Interventional Radiology, Guy's and St. Thomas' NHS Foundation Trust, St Thomas' Hospital, 1st floor, Lambeth Wing, Westminster Bridge Road, London, SE1 7EH, UK.
North Shore Hospital, Waitemata DHB, Auckland, New Zealand.
CVIR Endovasc. 2020 Sep 23;3(1):70. doi: 10.1186/s42155-020-00163-w.
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.
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.
The construction of a procedure-specific perioperative electronic proforma can save clinicians valuable time and encourage safe and effective clinical documentation.
在一家三级医院的介入放射科将其围手术期文档从纸质转换为使用标准化格式的电子文档的背景下，进行了一项研究，以确定这种变化对放射学引导血管造影程序的临床文档标准的影响。采用回顾性方法，按时间倒序分析围手术期记录以纳入研究。本次审核的标准是以所有血管造影程序的临床文档预期达到的最低标准形式制定的。
审核在三个等间隔的6个月时间段进行，共产生99份记录。对纸质记录的基线审核得出，在所测量的14个参数中有8个参数的完整性>80%，只有两个参数达到100%完整性的目标。对电子记录进行的第二个审核周期发现，与纸质记录相比，14个参数中有7个参数在完整性方面有绝对改善，但完整性超过80%的参数数量降至14个中的仅4个。同样，只有2个参数观察到100%的完整性。在最后一个审核周期中，引入标准化电子格式后，各方面表现均有所改善，14个参数中有6个达到100%的完整性，14个参数中有12个达到80%的完整性阈值。
构建特定程序的围手术期电子格式可以节省临床医生的宝贵时间，并鼓励安全有效的临床文档记录。
