An Audit of Dermatopathology Requisitions: Hand Written vs Electronic Medical Record Data Entry Accuracy
Christopher L Kinonen, William G Watkin, Briana C Gleason, Charnell EJ Johnson, Antoinette B Thomas, Thomas L Cibull. NorthShore University HealthSystem, Evanston, IL; Diagnostic Pathology Medical Group, Sacramento, CA
Background: At NorthShore University HealthSystem, dermatopathology (DP) case requisitions are received in hand written form or via electronic medical record (EMR). There are multiple categories for requisition data entry including patient demographics, physician name, and procedure site/date. Data entry error propagates inaccurate patient information and potentially delays billing/revenue collection. The DP service maintains a high case volume and thus systematic data entry problems potentially cause considerable documentation error. We reviewed DP data entry errors on hand written requisition forms compared to data entry errors via EMR.
Design: 11,475 DP requisitions (8,545 hand written, 2,930 EMR) were included in the study (4/1/2011-9/30/2011). Data entry errors were documented and categorized as cases were accessioned and reviewed.
Results: Results are illustrated in table 1.
|Category of error||# of hand written requisition errors||# of EMR requisition errors||Total # of errors|
|Mismatch between existing computer demographics/hand requisition||37||NA||37|
|Illegible requisition/container label||3||0||3|
|Requisition with incomplete/absent demographics||3||0||3|
|Requisition with no physician indicated||1||0||1|
|Requisition with wrong collection date||1||2||3|
|Specimen container not labeled||2||1||3|
|Specimen container with no patient name||10||0||10|
|Mismatch between patient name on requisition form/container||8||0||8|
|Specimen container with no procedure site||152||95||247|
|Mismatch between procedure site on requisition form/container||35||13||48|
|Wrong patient accessioned||4||0||4|
|Overall error rate||3.0%||3.9%||3.2%|