Table 1.
Patient record | Radiology exam order | MDTM | |
---|---|---|---|
Type of indicator | Composite score of conformity criteria | Composite score of conformity criteria | Compliance rate |
Items (N) | 10 Presence of: - surgical report - obstetrics report - anesthestic record - transfusion record - outpatient prescription - admission documents - care and medical conclusions at admission - in-hospital during prescriptions - discharge report (incl. information on care delivered and conclusions reached) Overall organisation of record (incl. physician's name, patient's name, and date of admission) |
4, Presence of:: - name of clinician ordering exam - type of exam requested - purpose of exam - patient information (name, age, key clinical history |
1 Record of one MDTM with date and names of three professionals |
Scoring method | 1 (present)/0 (absent) for each item |
1 (present for all 5 types of information)/0 (absence of one among the 5 type of information requested) | 1 (present)/0 (absent) (record reviewed with written conclusion) |
Data source | 80 random records | 130 random orders | 60 random new oncology outpatient records |
Hospitals (N) | 36 | 22 | 22 |
Calculations | Mean score for each medical record. Mean score for all records in sample (with 99% and 90% confidence intervals). Overall mean score for all hospitals. |
Mean score for all orders in sample (with 99% and 90% confidence intervals). Overall mean score for all hospitals. |
Mean score for all records in sample (with 99% and 90% confidence intervals). Overall mean score for all hospitals. |
Observations (N) | 13 899 | 4004 | 1378 |