Introduction: The medical record was defined by the Italian Ministry of Health in 1992 as "the information tool designed to record all relevant demographic and clinical information on a patient during a single hospitalization episode". Retrospective analysis of medical records is a tool for selecting direct and indirect indicators of critical issues (organizational, management and technical). The project’s aim being the promotion of an evaluation and self-evaluation process of medical records as a Clinical Risk Management tool to improve the quality of care within hospitals. Methods: The Authors have retrospectively analysed, using a validated grid, 1,184 medical records of patients admitted to the Teaching Hospital “Umberto I” in Rome during a three-year period (2013-2015). Statistical analysis was performed using SPSS for Windows © 19:00. All duly filled out criteria (92) were examined. “Strengths” and "Weaknesses" were identified through data analysis and Best and Bad Practice were identified based on established criteria. Conclusion: The data analysis showed marked improvements (statistically significant) in the quality of evaluated clinical documentation and indirectly upon behaviour. However, when examining some sub-criteria, critical issues emerge; these could be subject to future further corrective action.

Quality assessment of medical record as a tool for clinical risk management: a three year experience of a teaching hospital Policlinico Umberto I, Rome / Guzzo, Anna Santa; Tecca, Mario; Marinelli, Enrico; Bontempi, Claudio; Palazzo, Caterina; Ursillo, Paolo; Ferro, Giuseppe; Miani, Anna; Salvati, Annunziata; Catanzaro, Stefania; Chiarini, Massimiliano; Colamesta, Vittoria; Cacchio, Domenico; Sposato, DOMENICA PATRIZIA; Lombardi, ANNA MARIA; DE GIUSTI, Maria. - In: SENSES & SCIENCES. - ISSN 2284-2489. - 4:2(2017), pp. 371-379. [10.14616/sands-2017-2-371379]

Quality assessment of medical record as a tool for clinical risk management: a three year experience of a teaching hospital Policlinico Umberto I, Rome

Anna Santa Guzzo
;
Enrico Marinelli;Claudio Bontempi;Caterina Palazzo;Paolo Ursillo;Giuseppe Ferro;Anna Miani;Vittoria Colamesta;Domenico Cacchio;Domenica Patrizia Sposato;Anna Maria Lombardi;Maria De Giusti
2017

Abstract

Introduction: The medical record was defined by the Italian Ministry of Health in 1992 as "the information tool designed to record all relevant demographic and clinical information on a patient during a single hospitalization episode". Retrospective analysis of medical records is a tool for selecting direct and indirect indicators of critical issues (organizational, management and technical). The project’s aim being the promotion of an evaluation and self-evaluation process of medical records as a Clinical Risk Management tool to improve the quality of care within hospitals. Methods: The Authors have retrospectively analysed, using a validated grid, 1,184 medical records of patients admitted to the Teaching Hospital “Umberto I” in Rome during a three-year period (2013-2015). Statistical analysis was performed using SPSS for Windows © 19:00. All duly filled out criteria (92) were examined. “Strengths” and "Weaknesses" were identified through data analysis and Best and Bad Practice were identified based on established criteria. Conclusion: The data analysis showed marked improvements (statistically significant) in the quality of evaluated clinical documentation and indirectly upon behaviour. However, when examining some sub-criteria, critical issues emerge; these could be subject to future further corrective action.
2017
medical record; malpractice; quality; patient safety; validated grid
01 Pubblicazione su rivista::01a Articolo in rivista
Quality assessment of medical record as a tool for clinical risk management: a three year experience of a teaching hospital Policlinico Umberto I, Rome / Guzzo, Anna Santa; Tecca, Mario; Marinelli, Enrico; Bontempi, Claudio; Palazzo, Caterina; Ursillo, Paolo; Ferro, Giuseppe; Miani, Anna; Salvati, Annunziata; Catanzaro, Stefania; Chiarini, Massimiliano; Colamesta, Vittoria; Cacchio, Domenico; Sposato, DOMENICA PATRIZIA; Lombardi, ANNA MARIA; DE GIUSTI, Maria. - In: SENSES & SCIENCES. - ISSN 2284-2489. - 4:2(2017), pp. 371-379. [10.14616/sands-2017-2-371379]
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11573/1192234
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