Human poison exposure case documentation: Does the written documentation correlate with the voice recording?

• Published in: Clinical toxicology (Philadelphia, Pa.) Pa.), 2005-10, Vol.43 (6), p.765-766
• Main Authors: Jones Easom, LA, Benson, B E, Cumpston, K L
• Format: Article
• Language: English
• ISSN: 1556-3650

Written case records are used by poison centers to document telephone inquiries regarding poisoned patients. This documentation is used for patient care management, quality assurance, employee evaluation, guideline development, research, toxicosurveillance, and litigation. This study determined whether written case documentation correlated with the voice recordings for human poisoning exposure calls received by a regional poison control center. This project was conducted by a single auditor who randomly selected and reviewed Toxicall written records and the corresponding voice recordings (retrieved using Dictaphone ProLog). Inclusion criteria were that the case 1) was managed by a Specialist in Poison Information and 2) involved a human poisoning exposure. The auditor evaluated whether the documentation was an accurate reflection of the conversation; focusing on data elements that optimize patient care and/or the number of errors per case. Scoring graded the written documentation as either correlating or not correlating to the voice recording. Error types were categorized as: 1) information was stated verbally but not documented in the written record or 2) information was documented in the written record but not stated verbally. Errors were further categorized to identify specific types of discrepancies. 418 written records and corresponding voice recordings were audited from 11/02/00 to 01/28/05. There was acceptable verbal-to-written correlation for 317/416 (76%) of the cases reviewed. Cases that did not have acceptable verbal-to-written correlation had an average of 3 discrepancies per case. 74% of the errors were information stated but not documented; 26% were information documented but not stated. 76% of the cases at this regional poison control center had acceptable verbal-to-written correlation for case documentation. This establishes the baseline performance level for this center and can be used as a comparison point for other centers that choose to evaluate the correlation between voice recording and written case documentation.