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[How are radiographic examinations documented in medical records?]
1Røntgenavdelingen Haukeland Sykehus 5021 Bergen. ingfrid.haldorsen@haukeland.no
Background:
In order to improve the quality of our activity at the Department of Radiology, Haukeland University Hospital, we investigated how the referring clinical departments registered the results from diagnostic imaging.
Material And Methods:
We made a prospective registration of all hospitalized patients who received one or more diagnostic imaging or interventional procedures during a 24-hour period. Starting three months later, we performed a survey of how the radiological reports had been recorded by the referring departments.
Results:
Results from 11 of a total of 177 examinations (6%) could not be found in the medical records. Altogether 67 examinations (38%) were not mentioned even as a note in the patient files, and 57 examinations (32%) were not mentioned in the final report at discharge.
Interpretation:
In our opinion this study demonstrates a considerable potential for improvement in making important information more available to doctors, in the hospital and in general practice.