[The quality of medical records: a retrospective study in Lazio Region, Italy]. / La qualità della cartella clinica negli ospedali del Lazio.

ABSTRACT

INTRODUCTION: Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice. PURPOSE: We performed a retrospective study in order to assess the quality of medical records in the Lazio region. METHODS: From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires. RESULTS: A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items presence of anamnesis 98.1% (range from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate. CONCLUSIONS: Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.