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Auditing The Completeness and Legibility of Computerized Radiological Request Forms.

Yahya Al Muallem1, Majed Al Dogether1, Mowafa Househ2

  • 1College of Public Health and Health Informatics (CPHHI), King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), Riyadh, Kingdom of Saudi Arabia.

Journal of Medical Systems
|November 5, 2017
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Summary

Electronic medical imaging forms are more complete and legible than paper forms. This study found electronic systems improve data accuracy and user adherence in Saudi healthcare organizations.

Keywords:
Electronic medical recordHealth informaticsMedical-imagingPublic healthRadiologySaudi Arabia

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Area of Science:

  • Healthcare Informatics
  • Radiology Department Management
  • Medical Record Auditing

Background:

  • Manual, paper-based forms are used for outpatient transfers to medical imaging in Saudi healthcare.
  • The completeness and legibility of electronic medical imaging forms are not well understood.
  • Electronic medical record implementation is increasing in Saudi hospitals.

Purpose of the Study:

  • To audit and compare the completeness and legibility of paper-based versus electronic medical imaging forms.
  • To assess the number of errors present in both paper and electronic forms.
  • To evaluate the impact of electronic systems on data accuracy in medical imaging.

Main Methods:

  • Observational retrospective cross-sectional study design.
  • Audit of paper and electronic medical imaging forms collected between March 1 and May 15, 2015.
  • Chi-Square analysis to measure associations between categorical variables.

Main Results:

  • Electronic-based systems demonstrated significantly higher completeness compared to paper-based records.
  • Electronic forms were found to improve legibility and user adherence.
  • Electronic systems were associated with a reduction in data entry errors.

Conclusions:

  • Electronic-based medical imaging forms offer superior completeness and legibility over paper-based forms.
  • Future research should investigate other hospitals and conduct usability studies.
  • System design impacts the completeness and legibility of electronic medical imaging forms.