Medical record review in an employee cancer screening clinic

Documentation was evaluated through a series of chart reviews in the University of Texas M.D. Anderson Cancer Center's employee cancer screening clinic. One hundred charts were reviewed for three periods: 1987, before a QA program was established; 1988, during the QA program's introduction; and 1989, when chart review elements were identified. Documentation increased across these periods, with a significant increase for 10 of the 32 elements across at least two periods. However, mean follow-up time (initial examination to referral and communication of test results) did not vary across time, averaging 14 days. A new computer-based data system should help reduce follow-up time and facilitate access to data on patient compliance regarding tests and referrals.