A surveillance-oriented medical record as a source of data for both drug and quality of care surveillance.

ABSTRACT

The medical record for hospitalized patients has been modified in order to orient it towards two types of surveillance adverse drug reactions (ADRs) and the quality of medical care. The modification consists of an adaptation of the progress notes; the transfer of the information to a special database is facilitated by the use of a simple system of codes that identify and correlate the items necessary for surveillance purposes. During the 6 months of observation of the 1103 pediatric patients included in the study, 35 clinically important suspected ADRs were noted by physicians. For the quality of medical care surveillance, all drug prescriptions were evaluated and areas in which to intervene in order to improve the appropriateness of prescriptions were identified. Quality surveillance was also extended to the monitoring of 'unexplained' adverse events for which no particular cause was attributable. We consider it advantageous to carry out these two types of surveillance simultaneously because they require many common items of information. The use of an oriented medical record as a source of data makes it possible to integrate surveillance with everyday ward activities.