Documentation of blood culture results

To evaluate the adequacy of documentation of blood culture results in patients' medical notes.

A pro-forma was completed following review of medical notes at 24 and 48 hours after a blood culture had been reported as positive. The study was performed on blood cultures received at the Department of Microbiology, Royal Hallamshire Hospital, Sheffield, from two local hospitals. Two periods were studied: (A) May to June 1993 and (B) September to October 1993.

There were 43 results studied in period A and 79 in period B, giving a total of 122 results studied. Overall, 72 (59%) of 122 results were recorded in the medical notes at 24 hours. Of those results deemed highly significant, 40 (63%) of 63 were recorded. There was no significant difference in the documentation of results if the result was given personally or via the telephone. Nor was there any difference in documentation between different medical grades. Throughout the study there were six inaccurate records. The cumulative documentation over 48 hours of positive results was 54 (86%) of 63 of highly significant, 27 (69%) of 39 of uncertain significance, and 11 (55%) of 20 probable contaminant results.

Documentation of blood culture results is currently suboptimal.