Company project: "Evaluation of the quality of medical records as a tool of clinical risk management"

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, technical and professional issues). The project’s purpose being the promotion of an evaluation and self-evaluation process of the medical records as a clinical risk management tool, in order to improve the quality of care within the company. Methods/design: The Authors have retrospectively analyzed a total of n. 1184 medical charts of patients admitted to Teaching Hospital “Umberto I” in Rome during in 2013 ( n. 518) and 2015 (n. 666) . Statistical analysis was performed using SPSS for Windows © 19:00. all duly filled out criteria (92) were examined. Strengths” and " Weaknesses " have been identified from data analysis and on the basis of the established criteria to identify Best Practices and Bad Practice. Results and Conclusion: The data analysis showed marked improvements (statistically significant) of the quality of evaluated clinical documentation and indirectly of behavior. However, when taking into account some sub-criteria, critical issues emerge; these issues taking into account company priorities, could be subject in the future to further corrective actions.

Keywords

• medical record
• malpractice
• quality
• patient safety