title: Adequacy of physician documentation of red blood cell transfusion and correlation with assessment of transfusion appropriateness.
abstract: BACKGROUND
  A major function of the hospital transfusion service is to assess the appropriateness of blood transfusion. Inadequate documentation of transfusions may hamper this assessment process.
  
  
  OBJECTIVE
  To correlate the level of physician documentation of transfusion with the ability to justify transfusion.
  
  
  METHODS
  Retrospective review of red blood cell transfusions in adult patients in 2 hospital facilities during 1-week audit periods of each month from April 2001 to March 2003. Assessment forms were used to classify the level of physician documentation of transfusions into 3 groups: adequately, intermediately, and inadequately documented. Transfusions were deemed justified or not via comparison with hospital transfusion guidelines.
  
  
  RESULTS
  There were 5062 audited red blood cells transfused to 2044 adult (> or = 18 years) patients. Medical records from 154 patients transfused with 257 units of red blood cells during 172 transfusion events were reviewed after initial screenings of hemoglobin/hematocrit values failed to justify the transfusions. Nine percent of adequately documented, 50% of intermediately documented, and 73% of inadequately documented transfusion events could not be justified. Transfusion events with suboptimal (intermediate and inadequate) documentation accounted for 49% of all medical record-reviewed transfusion events and 62% could not be justified. The correlation between inadequate documentation and failure to justify transfusion was significant (P < .001), as was the correlation between suboptimal documentation and failure to justify transfusion (P = .03).
  
  
  CONCLUSIONS
  There is a significant correlation between suboptimal documentation and failure to justify transfusions. Educating clinicians to improve documentation along with appropriate indications for transfusions may enhance efficiency of blood utilization assessment and lead to reduced rates of unjustifiable transfusions.
authors.affiliation: Department of Pathology and Laboratory Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10019, USA. markfriedman@chpnet.org
authors.forename: Mark T
authors.initials: MT
authors.lastname: Friedman
authors.forename: Amber
authors.initials: A
authors.lastname: Ebrahim
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004282:Documentation / Q000592:standards*; D017707:Erythrocyte Transfusion / Q000706:statistics & numerical data*; D005260:Female; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D008485:Medical Audit; D008499:Medical Records; D008875:Middle Aged; D010820:Physicians; D017410:Practice Guidelines as Topic; D011364:Professional Practice / Q000592:standards* / Q000706:statistics & numerical data; D012189:Retrospective Studies