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. 2010 Apr 8;10:93. doi: 10.1186/1472-6963-10-93

Table 1.

QI description

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