Clinical Chart Audits as a Potential Process Improvement Strategy Within the Radiation Therapy Department of a Community-Based Cancer Center

摘要

Purpose: Within the health care profession, many organizations rely-on routine clinical chart audits to detect areas for enhancement and potential triggers for error. Effective clinician documentation within the electronic treatment record is mandatory should high-quality care be maintained. This study aimed to determine what type of information might be obtained from radiation therapy treatment chart audits. This information would help to inform areas for improvement within the department and to determine whether introducing clinical chart audits as routine would be of benefit. Methods: A chart audit tool was piloted at the host institution and subsequently finalized as a result of the pilot. Clinical chart audits of radiation treatment records (n = 196) were completed over a four-month time span. Data analysis included the calculation of proportions to examine the completeness of each of the identified tasks within the chart audit tool. Results: Areas of excellent practice (achieving or exceeding a benchmark measurement of 90%) tend to correlate well with tasks that are currently embedded into routine quality assurance checks, such as a checklist. Areas for improvement (below set benchmark) have a commonality; they all required best practices to be followed and did not have a prompt built in to the process. Conclusions: Areas of further related research would focus on engaging radiation therapists in the successful implementation of chart audits within this radiation therapy department.