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

Abstract

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.

Complications in Interventional Radiology: the role of clinical governance and iterative hospital systems in quality improvement

“…Such guidelines allow for updating against rapidly-evolving evidence and ensure that steps reviewed in a risk-based pathway can be re-integrated in a prevention mindset. The use of “time-out” processes, which are based on the early concept of surgical checklists, is an example where these concepts were implemented after adverse events in order to prevent potential future incidents of consent or wrong-site operating [ 29 ].…”