[Quality of medical records in Naples (Italy) 2nd University School of Medicine]. / Qualità di compilazione delle cartelle cliniche nell'Azienda Ospedaliera Universitaria di Napoli.

ABSTRACT

To evaluate and improve the quality of medical-record keeping, in clinics and surgery departments. The evaluation involved 66 Operative Units (O.U.) of the "2nd University Hospital" in Naples (Italy). 10 medical records for each O.U. were randomly selected, for a total of 660. The quality was evaluated in all sections of medical records using the criteria of completeness, clarity and traceability of the data. The most critical issues are unclear handwriting in almost all sections, in the whole scarse presence of a discharge letter (17.0%) in surgery (1.4%), almost total absence of the physicians signature in the clinical diary (2.3%). The completeness of medical records (presence of patient's history, physical examination, informed consent) is significantly higher in the surgery departments. The medical records are significantly righter in the clinic departments. In general, a poor quality of medical-record keeping was detected. This indicates the need to improve the quality by involving the staff in the importance of correct compilation.