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Standardization in Documentation Format Can Significantly Reduce Manual Data Entry Error in Patient Chart


S Zhou

S Zhou*, S Chen, A Wahl, C Enke, University of Nebraska Medical Center, OMAHA, AA

SU-E-T-206 Sunday 3:00:00 PM - 6:00:00 PM Room: Exhibit Hall

Purpose: To demonstrate that standardization in documentation format can significantly reduce manual data entry error in patient chart.
Method and Materials: Due to lack of direct data link between CT on rail imaging registration software and patient R&V system, therapists have to manually enter translation correction of patient position into R&V system after performing imaging registration between CT image taken just before treatment delivery and treatment planning CT image. Approximately six months after CT on rail was placed into clinical service, we started requiring therapists to use a standard format to document the shifts when they manually enter data to reduce manual data entry error rate. The therapist manual data entry errors in R&V system before (551 entries) and after the format standardization (1645 entries) are the subjects of statistical analysis. The errors are divided into two categories (recoverable and non-recoverable errors) depending on whether a human being can recover the translation shifts in lateral, longitudinal, and vertical directions from the therapist notes. Fisher's exact test is performed to test the statistical significance of therapist's data entry error reduction after our imposing the documentation format requirement. Temporal information on when the errors were made is also analyzed to find out when errors are more likely to happen.
Results: Statistical analysis indicated that reductions in the numbers of recoverable, non-recoverable, and total errors after standardization in document format are all statistically significant with p values less than 0.05.
Conclusion: A simple and low cost measure like standardization in document format can significantly reduce the errors operators introduce to patient R&V system when they perform manual data entry. We hope our experience will convince people to follow more disciplined documentation rule to reduce the error rate and therefore potentially can improve the quality of patient care when manual data entry is involved.


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