Good record keeping maximises patient safety and quality of care. The Royal College of Physicians recommends that ‘medical records should have a standardised structure and layout’ (RCP Generic Record Keeping Standards 2007). Pictorial representation of respiratory examination using a cartoon of the lungs annotated with lines, squiggles, crosses and musical notes is commonplace despite lack of standardisation and formal teaching. Our study aimed to assess the accuracy of interpretation and the rationale behind use of pictorial representation.
Methods Questionnaire survey correlating six common pictorial representations A–F (see Abstract P85 Figure 1) with clinical findings as follows: 1=coarse crepitations, 2=wheeze, 3=bronchial breath sounds, 4=decreased bronchial sounds, 5=pneumonectomy, 6=pleural effusion, 7=rhonchi, 8=fine end inspiratory crepitations, 9=bibasal crepitations, 10=transmitted upper airway sounds, 11=absent breath sounds, 12=pneumothorax, 13=other(specify). Multiple responses were allowed for the same picture.
Results 88 clinicians completed the survey (Foundation Year n=44, Specialist Trainee n=10, Specialist Registrar n=13, Consultant n=16, other n=3). 74/88 (84%) admitted to routinely drawing pictures. Of these 71/74(96%) also recorded findings in written text. 23/71 (32%) could not provide a reason for their use of drawings though 26/71(37%) reported that it aided communication. Most learned their behaviour from senior colleagues (22/76), own observation (16/76) or medical school (27/76). The closest associations were for Pictures C (77/78 responses, 99%=normal) and E (94/102,92%=wheeze/rhonchi combined). Crosses were commonly interpreted as crepitations in Pictures B (89/101,88%=fine and bibasal combined) and F (66/94, 70%=coarse). Pleural effusion was most commonly linked to Pictures A (35/107, 33%) and D (75/98, 77%) though both of these had an additional eight and four interpretations respectively.
Conclusion The majority of doctors use pictorial representation to record respiratory examination. Lack of standardisation leads to variation in annotation and potentially alternative interpretation by others. With the exception of Picture C, the use of pictures alone is unreliable. Reassuringly for patient safety, most doctors also write down their findings. Pictorial representation is most often informally learned and appears to be well established in UK medical practice.