Quality improvement of medical records in a teaching hospital

INTRODUCTION

The aim of this study was to evaluate the quality of the MR compilation in some Operative Units of the "Azienda Ospedaliera Universitaria--II Università di Napoli" (AOU- SUN)-Italy, before and after an intervention of quality improvement, underlining the potential differences in the behaviour of different specialists (physicians vs. surgeons).

METHODS

Two random samples of 660 MRs were reviewed. A four-step program was developed: (1) first assessment of the MR; (2) implementation of the MR quality, sending a letter with the purpose of the study, the results obtained in the first step from that ward, the guidelines to correctly fill out the MR; (3) follow-up step four months later; (4) comparison of the data before and after the distribution of the guidelines using indicators of completeness of all sections of MR, clarity of handwriting and presence and clarity of signature.

RESULTS

The main concerns were related to the signature of the duty physician (present in 2.0% and legible in only 15.4%), the presence of the letter of discharge (18.0%) and the clarity of the days of hospital stay (32.0%). After the intervention the improvement of the quality of compilation was modest and regarded mainly medical rather than surgical wards.

DISCUSSION AND CONCLUSIONS

The improvement was not satisfying since from a medical and a legal point of view the indicators should reach 100% of clarity and completeness. A further study is being carried out to improve the involvement of health care professional, so that such requirements will be perceived as a common goal, not as mere bureaucratic initiatives.

[Quality of medical records in Naples (Italy) 2nd University School of Medicine]

To evaluate and improve the quality of medical-record keeping, in clinics and surgery departments. The evaluation involved 66 Operative Units (O.U.) of the "2nd University Hospital" in Naples (Italy). 10 medical records for each O.U. were randomly selected, for a total of 660. The quality was evaluated in all sections of medical records using the criteria of completeness, clarity and traceability of the data. The most critical issues are: unclear handwriting in almost all sections, in the whole scarse presence of a discharge letter (17.0%) in surgery (1.4%), almost total absence of the physicians signature in the clinical diary (2.3%). The completeness of medical records (presence of patient's history, physical examination, informed consent) is significantly higher in the surgery departments. The medical records are significantly righter in the clinic departments. In general, a poor quality of medical-record keeping was detected. This indicates the need to improve the quality by involving the staff in the importance of correct compilation.