Quality improvement of medical records in a Teaching Hospital

Objective: To evaluate and improve the quality of medical records compilation, comparing medical and surgical area. Methods: The evaluation concerned 66 Operative Units (O.U.) of the “Azienda Ospedaliera Universitaria - Seconda Università di Napoli” (Italy); 10 medical records for each O.U. have been randomized for a total of 660. The quality has been evaluated analysing all sections of medical records and using criteria of completeness, clarity and traceability of the data reported. After the analysis the Authors discussed the detected critical points with the chiefs of the O.U. and gave them appropriate guidelines of correct compilation. The next step is a revaluation of a new set of medical records to check the possible quality improvement. Results: The indicators show different degrees of default. The most critical points are: the unclearity of handwriting in almost all sections, the low presence of discharge letter (17%), the almost all absence of physicians signature in the clinical diary (2.3%). The completeness of medical records (presence of patient’s history, physical exam, informed concent) is significantly higher in the surgical area. The medical records are significantly more clear in the medical area. Conclusion: In general, a poor quality of medical records compilation has been detected. That suggests the need to improve quality compilation through an involvement of the operators and the adoption of guidelines