Documentation of positive blood culture results in a London teaching hospital.
Cooke FJ., Richards DB., Breathnach AS.
OBJECTIVES: Our current practice is that initial (day 1) positive blood culture results are communicated to clinical teams; the task of recording those results in the notes is left to the clinical team. Microbiological information may be of crucial importance to an on-call doctor asked to review an unwell patient. We therefore sought to establish the extent to which day 1 positive blood culture information is available in patients' notes and its accuracy. METHODS: There were 51 positive blood cultures over a 14-day period. Patient notes of 39 of these were available for examination for evidence of the day 1 culture report, the accuracy of that report and evidence of clinical interpretation. RESULTS: The proportion of notes with a record was disappointingly low (54%), although the record was almost always accurate. Results reported at the weekend were as likely to be recorded in the notes as those given during the week. CONCLUSION: On-call doctors, not previously acquainted with a patient, will find that important information about day 1 positive blood culture results is not available to them in patient notes in around half of all cases. This adds weight to the view that medical microbiologists should give greater priority to ward visits and documentation of significant results, thus ensuring continuity of care from the laboratory bench to the bedside.