Clinical Record: Oncological Screening

Author(s):  
Raquel Benlloch Rodríguez
2010 ◽  
Author(s):  
Robin Krajewski ◽  
Michael Hoffman
Keyword(s):  

2013 ◽  
Vol 124 (5) ◽  
pp. 322-330 ◽  
Author(s):  
Natalia Niedziela ◽  
Monika Adamczyk-Sowa ◽  
Krystyna Pierzchała

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
A Ghareib ◽  
Z Vinnicombe ◽  
G Visser ◽  
A Ra ◽  
M Mantella ◽  
...  

Abstract Introduction St. George’s University Hospitals NHS Foundation Trust is a tertiary plastic surgery centre serving a population of 3.5 million in and around South West London. Telemedicine Referral Image Portal System (TRIPS) is integral to our service, allowing triage of patients in remote locations. During Covid, TRIPS helped in reducing footfall and streamlining out of hospital referrals to reduce unnecessary transfer. The aim of this project was to assess the quality of clinical documentation for emergency referrals to plastic surgery via TRIPS. Method We performed a retrospective review of all patients referred to plastic surgery via TRIPS during April 2020. Documentation standards were determined from national guidance. After introduction of a condensed guide, a second review was performed four months later. Results In April, 131 referrals were recorded on TRIPS. Only 22.9% of records met the standard. The most common omission was treatment advice. Following introduction of guidance, 215 TRIPS records were reviewed. The quality of clinical documentation improved in all aspects with a compliance rate of 89%. Conclusions Although TRIPS remains a useful tool for triage, it is a clinical document and must meet the standards of clinical record keeping. Introduction of clear guidelines improves overall compliance.


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