How good are case notes in the audit of radiological investigations?
Audit based on the use of case notes completed in the ordinary course of patient care has not been widely used because of concern about the completeness and adequacy of such records. This paper describes the results of a study carried out to assess whether information contained in case notes was sufficiently reliable to enable clinical effectiveness to be measured. The study examines the extent to which a radiologist and an epidemiologist agree with two experienced clinicians in making retrospective judgements on whether out-of-hours radiological investigations are worthwhile. There was a high measure of agreement; only a relatively small amount of information in the case notes is needed to make valid judgements on clinical performance. The method described here may be applicable to other diagnostic investigations and the results of the study have wide implications for more effective and efficient management of resources within the NHS.
Department of Epidemiology and Community Medicine, University of Wales College of Medicine, Heath Park, Cardiff.
M C
MC
Charny
G M
GM
Roberts
P
P
Beck
D J
DJ
Webster
C J
CJ
Roberts
D002983:Clinical Competence; D004282:Documentation / Q000592:standards; D006748:Hospital Departments / Q000592:standards*; D006801:Humans; D007600:Judgment; D008485:Medical Audit / Q000379:methods*; D008499:Medical Records / Q000592:standards*; D015588:Observer Variation; D011859:Radiography; D011872:Radiology Department, Hospital / Q000592:standards*; D012680:Sensitivity and Specificity; D013997:Time Factors; D014852:Wales