Patient Informatics

4. Ensuring good quality electronic patient documentation

All clinical examinations of any kind must contain accurate and securely recorded detail. As a minimum, data that should be captured will be the information on a standard request form:

  • Patient salutation, gender, first and last name;
  • Patient date of birth;
  • A unique identifier for the patient (hospital or other national number);
  • The source of referral (ward or department) – who the results should be shared with in the absence of the requesting clinician;
  • The requesting clinician and the clinical information supplied by them (examination requested, reason for examination, clinical question to be answered);
  • Date and time of exam;
  • Unique identifier for each image or imaging acquisition (usually an accession number), along with the orientation of any image, laterality;
  • The total number of images.

If no suitable I.T. system such as a RIS is available, then a spreadsheet application such as Microsoft Excel, Google Sheets or even a suitable paper book may be used.

It is important that the initial acquisition, generation and recording of data is accurate, as amendments at later dates are harder to make.