title: Ten-year results of quality assurance in radiotherapy chart round.
abstract: BACKGROUND
  The Royal Australian and New Zealand College of Radiologists (RANZCR) initiated a unique instrument to audit the quality of patient notes and radiotherapy prescriptions. We present our experience collected over ten years from the use of the RANZCR audit instrument.
  
  
  METHODS
  In this study, the results of data collected prospectively from January 1999 to June 2009 through the audit instrument were assessed. Radiotherapy chart rounds were held weekly in the uro-oncology tumour stream and real time feedback was provided. Electronic medical records were retrospectively assessed in September 2009 to see if any omissions were subsequently corrected.
  
  
  RESULTS
  In total 2597 patients were audited. One hundred and thirty seven (5%) patients had one hundred and ninety nine omissions in documentation or radiotherapy prescription. In 79% of chart rounds no omissions were found at all, in 12% of chart rounds one omission was found and in 9% of chart rounds two or more omissions were found. Out of 199 omissions, 95% were of record keeping and 2% were omissions in the treatment prescription. Of omissions, 152 (76%) were unfiled investigation results of which 77 (51%) were subsequently corrected.
  
  
  CONCLUSIONS
  Real-time audit with feedback is an effective tool in assessing the standards of radiotherapy documentation in our department, and also probably contributed to the high level of attentiveness. A large proportion of omissions were investigation results, which highlights the need for an improved system of retrieval of investigation results in the radiation oncology department.
authors.affiliation: Bendigo Base Hospital, Bendigo, Australia.
authors.forename: Bardia
authors.initials: B
authors.lastname: Taghavi Bayat
authors.forename: Suki
authors.initials: S
authors.lastname: Gill
authors.forename: Shankar
authors.initials: S
authors.lastname: Siva
authors.forename: Keen Hun
authors.initials: KH
authors.lastname: Tai
authors.forename: Michael Lim
authors.initials: ML
authors.lastname: Joon
authors.forename: Farshad
authors.initials: F
authors.lastname: Foroudi
mesh_terms: D001315:Australia; D054869:Clinical Audit / Q000379:methods*; D003133:Commission on Professional and Hospital Activities; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D009520:New Zealand; D018024:Peer Review, Health Care / Q000379:methods / Q000592:standards*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000706:statistics & numerical data* / Q000639:trends*; D011878:Radiotherapy / Q000592:standards*