Auditing The Completeness and Legibility of Computerized Radiological Request Forms

摘要

Certain Saudi healthcare organizations transfer outpatients to medical imaging departments for radiological examinations in a manual process that relies on the use of paper-based forms. With the increased implementation of electronic medical records in Saudi Hospitals, little is known about the completeness and legibility of information captured in electronic-based medical imaging forms. The purpose of this study is to audit the completeness and legibility of medical imaging paper-based forms in comparison with electronic-based medical imaging forms. As a secondary objective, we also examined the number of errors found on the forms.An observational retrospective cross-sectional study was utilized to audit the completeness and legibility of both paper and electronic forms collected between March 1 and May 15, 2015. The study measured the association among categorical variables using Chi-Square analysis. The results of this investigation show a significant association between form completion and type of record (i.e., paper vs. electronic) where electronic-based systems were found to be more complete than paper-based records. Electrnoic based records were also found to improve form legibility, promote user adherence to complete the forms and minimize entry errors. In conclusion, electronic-based medical imaging forms are more complete and legible than paper based forms. Future studies should evaluate other hospitals and compare both legibility and completeness of electronic-based medical imaging forms and conduct usability evaluation studies with users to explore the impacts of system design on both completeness and legibility of electronic forms, in general, but more specifically, electronic-based medical imaging forms.