Integrated medical records for surgical services: a new tool for a new hospital model

According to a modern definition, the patient's medical record is a tool shared by health-care professionals whose purpose is to support the planning, providing and documenting of patient-centred care. The requirements and regulations of medical records, which date back to the sixties, need now be adapted to more recent organisational models based on different levels of care intensity and strongly integrated patient-oriented care approaches designed to create connectivity, alignment and collaboration within and between different professional fields. On this basis, the SS. Cosma and Damiano Hospital Chief Physician endorsed a multiprofessional project providing for the complete reorganisation of surgical activities according to the above-mentioned approach and, at the same time, for the elaboration of an "integrated" medical record, capable of overcoming the traditional separation between medical and nursing documents. This paper presents the results of a long period of complex teamwork consisting in revising and sharing a new medical record model based on principles of professional integration and patient-centredness in health-care provision.