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research
Quality assessment of medical record as a tool for clinical risk management: a three year experience of a teaching hospital Policlinico Umberto I, Rome
Authors
Claudio Bontempi
Domenico Cacchio
+14 more
Stefania Catanzaro
Massimiliano Chiarini
Vittoria Colamesta
Maria DE GIUSTI
Giuseppe Ferro
Anna Santa Guzzo
ANNA MARIA Lombardi
Enrico Marinelli
Anna Miani
Caterina Palazzo
Annunziata Salvati
DOMENICA PATRIZIA Sposato
Mario Tecca
Paolo Ursillo
Publication date
1 January 2017
Publisher
Doi
Cite
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
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Last time updated on 18/03/2019