A Data Audit: Tool for Good Clinical Practice

S. Chockalingam

HOD – Department of Orthopaedics, Kauvery Hospital, Trichy

Introduction

The clinical data was collected during the course of patient care or as part of clinical research.

Electronic medical records were compiled with the data collected during the course of patient care.

The clinical data is a staple resource for health and medical research and analysis of the data enables us to gain new knowledge. That also helps to guide the development of best practices, which is essential to health care improvement.

Types of clinical data

Parametric Data

Follows normal distribution

Non-Parametric Data

Does not follow normal distribution

Below is an example of parametric data.

Background

Vertebral Compression Fracture (VCF), post op management of osteoporosis:

The authors had taken all patients with a diagnosis of VCF from the hospital spine database and reviewed the data. They reviewed the number of patients with VCF, the incidence of osteoporosis and post fracture management of osteoporosis and published in AAOS journal.

For this study, the data from the hospital database were used.

Aim and objective of “A Data Audit” at Kauvery Hospital, Trichy

To do an audit (study), we need a data. Multiple personnel collect data at multiple points. To do a meaningful study, audit or research, the data needs to be accurate.

Aim: To study the accuracy of data collected in OT, by auditing the Data.

Materials

Hospital database of patients who underwent surgery
Period from 2018–2024
Orthopaedic surgeries sample taken for the study
Single surgeon- patients to reduce variability
Same surgeon analysed the data.

Methods

Diagnosis and surgery matching
Appropriateness of diagnosis documentation
Appropriateness of surgery documentation.

Results and Discussion

Data accuracy

341 patients who had surgery under my care were audited
164 patients had diagnosis related to surgery
147 patients’ diagnosis is not at all correct or appropriate
30 patients’ diagnosis could have been more accurate

Not accurate diagnosis

A very lenient analysis

Domestic fall
RTA
Self-fall
Congenital disorder
Fracture
Implant removal

Wrong Diagnosis

S. No	Wrong Diagnosis	Procedure
1	Rib fracture	Femur fracture fixation
2	Rheumatoid arthritis	ACL reconstruction
3	ACL tear (knee)	Shoulder Arthroscopy
4	Spinal cord compression	ORIF radius
5	Osteoarthritis knee	Hip Replacement
6	Diabetes Mellitus Foot	Tendon Transfer (4-year-old child!).

Inappropriate diagnosis

S. No	Inappropriate diagnosis	Procedure
1	Branchial cyst	ACL reconstruction
2	Lower Respiratory TI	Hip Replacement
3	Intra cerebral haemorrhage	Tibia plating
4	Hand Pain	Total hip replacement
5	Preterm RDS	Foreign body removal
6	Bilateral Gynaecomastia	Bilateral Achilles tenotomy (1 year old)!

Surgery

For a specific surgery of 52 patients

ACL reconstruction: Only three patients had surgery related diagnosis

Unrelated Diagnosis
1	Leg pain	7	Dislocation knee
2	Femur fracture	8	Septic arthritis
3	Osteoarthritis	9	Rheumatoid arthritis
4	Arthritis	10	Transient ischemic attach
5	Hypospadias	11	Fracture crown
6	Infected cyst

Inaccurate name of surgery

Small numbers only,

S. No	Inaccurate surgery	Diagnosis
1	Bone Excision	Fracture neck of femur
2	ORIF PCL Plating	Fracture femur
3	Decompression	Fracture femur
4	Open revision femoral bone	Child complex hip reconstruction

Study Findings

Diagnosis is wrong or inappropriate in many patients
Surgery name is wrong for few patients
Diagnosis and surgery does not match in many patients
The diagnosis in the EMR was made not by the surgeon, or nurse or secretary in OT but by a secretary at the time of admission
The theatre secretary enters the surgery name from the operation notes.

Suggestions for improving data accuracy

The Surgeon and his/ her team should authorise or enter the data
The staff should be trained
ICD coding should be used
Training for all surgeons and staff involved in coding
Diagnosis about surgery should be editable by the surgeon or the treating doctor’s team.

Take Home Message

If we want to review our data, present, and publish, then the data entry should be accurate. Action needs to be taken from all stakeholders to improve the accuracy of Data

Acknowledgment

Ortho Team members, OT staff and Secretaries at Cantonment.

Dr Chokalingam

Dr. S. Chockalingam
HOD – Department of Orthopaedics

A Data Audit: Tool for Good Clinical Practice

A Data Audit: Tool for Good Clinical Practice

S. Chockalingam

Journals