Evaluation of the Descriptions of the Radiological Findings in Inpatient Charts at Juntendo University Hospital

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  • 順天堂大学病院診療録におけるX線所見記載の現況

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Good descriptions on medical chart are essential for modern multidisciplinary medicine. In this particular series, evaluation of the descriptions of the radiological findings was carried out on medical records at Juntendo University Hospital. One thousand inpatient charts drawn up during calendar 1981 were randomly selected and descriptions of radiological findings were evaluated. In addition, fifty inpatient charts each were randomly selected from the Departments of Internal Medicine and Surgery. They were evaluated on the description of radiological findings in terms of date of the examination, method of the examination, contents of the report, recommendation of further examination and doctor's signature. There were 7096 requests for radiological examination in the 1000 randomly selected inpatient charts, and 3717 (52.4%) corresponding descriptions of the findings were present. The schema was the most popular medium of description (67%) followed by Japanese (16.9%) and foreign language (mainly English, 16.1%). The description of the findings was better in nonsurgical charts.The description of the special radiological examinations was better than nonspecial radiological examinations. The further evaluation of 100 surgical and nonsurgical charts showed a similar tendency. There were 404 descriptions in the surgical charts and 328 in the nonsurgical charts. Analyses of the descriptions showed the following results. The date of examination was seen in 39% of the surgical charts and 51% of the nonsurgical charts. The method of examination was seen in 57% of the surgical charts and 67% of the nonsurgical charts. The contents of the description were better in the nonsurgical charts. Recommendations for further examination were seen in 10% and 20% of the descriptions, and doctor's signatures were seen in 7% and 39% respectively. Offical reports were of course better on all aspects of the descriptions. The results we obtained were quite disappointing and further effort is strongly required for better clincal medicine and clinical research.

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