An audit of dermatopathology requisitions: Hand written vs. electronic medical record data entry accuracy

摘要

Background At our institution, dermatopathology case requisitions are received in hand written form or via electronic medical record (EMR). Categories for requisition data entry include patient demographics, physician name and procedure site/date. Systematic data entry problems potentially cause considerable documentation error, propagate inaccurate patient information and potentially delay billing/revenue collection. Method We compared dermatopathology data entry errors on hand written requisitions to data entry errors using the EMR. A total of 11,475 requisitions (8545 hand written and 2930 EMR) were included in the study (the time frame was 4/1/2011-9/30/2011). Results For hand written requisitions, there were 258 data entry errors on 8545 specimens (3.0%). For requisitions entered via EMR, there were 113 errors on 2930 specimens (3.9%). Container labeling, which is a hand written process with both requisition methods, was the most common source of error. Conclusions Currently, even with an EMR, containers are at least partially hand labeled and 96% of EMR errors occurred during this process. Other EMR data entry errors are extremely uncommon (4/2930 cases). This suggests introduction of a labeling process entirely linked to EMR data entry could nearly eliminate data entry errors. Although this study focused solely on dermatopathology cases, the findings can be extrapolated to all types of specimens.