Improving the Transcription of Patient Information From Image Requisitions to the Radiology Information System
Department of Radiology
Health and Medical Administration | Health Information Technology | Radiology
PURPOSE: The purpose of this study was to improve the transcription of patient information from imaging study requisitions to the radiology information database at a single institution.
METHODS: Five hundred radiology reports from adult outpatient radiographic examinations were chosen randomly from the radiology information system (RIS) and categorized according to their degree of concordance with their corresponding clinical order indications. The number and types of grammatical errors and types of order forms were also recorded. Countermeasures centered on the education of the technical staff and referring physician offices and the implementation of a checklist. Another sample of 500 reports was taken after the implementation of the countermeasures and compared with the baseline data using a chi2 test.
RESULTS: The number of RIS indications perfectly concordant with their corresponding clinical order indications increased from 232 (46.4%) to 314 (62.8%) after the implementation of the countermeasures (P < .0001). The number of partially concordant matches due to inadequate RIS indications dropped from 162 (32.4%) to 114 (22.8%) (P < .001), whereas the number of partially concordant matches due to inadequate clinical order indications increased from 22 (4.4%) to 57 (11.4%) (P < .0001). The number of discordant pairings dropped from 84 (16.8%) to 15 (3%) (P < .0001). Technologists began to input additional patient information obtained from the patients (not present in the image requisitions) in the RIS after the implementation of the countermeasures.
CONCLUSIONS: The education of technical staff members and the implementation of a checklist markedly improved the information provided to radiologists on image requisitions from referring providers.
CPOE, Patient information, RIS, RIS indication, clinical order, communication, computerized physician order entry, image requisition, improvement, improving, improving communication, indication, radiology information system, technologists, transcribing information, transcription
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Citation: J Am Coll Radiol. 2016 May 25. pii: S1546-1440(16)30174-0. doi: 10.1016/j.jacr.2016.03.030. [Epub ahead of print] Link to article on publisher's site
Journal of the American College of Radiology : JACR
DiRoberto, Cole; Lehto, Crystal; and Baccei, Steven J., "Improving the Transcription of Patient Information From Image Requisitions to the Radiology Information System" (2016). Radiology Publications and Presentations. 166.