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.