Accuracy and completeness of the documentation of blood culture results
Heard and colleagues1 raise the thorny issue of how important microbiological results and advice should be recorded in patients’ notes and by whom. Reported here is a prospective audit identifying how accurately this is done. It was decided that the audit should concentrate on blood cultures yielding a clinically significant isolate, a finding that all members of staff should consider as important and worthy of prompt documentation.
This work was performed in a 1045 bed hospital where all Gram stain and culture results from clinically significant blood cultures are telephoned by a medical microbiologist to either the attending doctor or to qualified nursing staff on the ward. It is expected that the information and advice given over the telephone should be promptly documented in the patient’s notes and that nursing staff would contact the patient’s attending doctor. Where it is clear from nursing staff that the patient is still septic, …
