Cardo S, Agabiti N, Picconi O, Scarinci M, Papini P, Guasticchi G, Gentile D, Forastiere F, Arcà M, Volpe M, Perucci C A
Agenzia di Sanità Pubblica del Lazio, Roma.
Ann Ig. 2003 Sep-Oct;15(5):433-42.
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.
We performed a retrospective study in order to assess the quality of medical records in the Lazio region.
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.
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.
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.
病历在不同医疗服务提供者之间的沟通以及法医学中发挥着重要作用。在意大利，关于病历完整性和正确性的信息匮乏，而未来的医院认证可能会将其质量作为良好医疗实践的一个指标加以考量。
我们开展了一项回顾性研究，以评估拉齐奥地区病历的质量。
从地区医院信息系统中登记的123家医院的37009例因五种不同疾病（急性心肌梗死（AMI）、冠状动脉搭桥手术、肺炎、脑血管疾病、乳房手术）出院病例中，我们随机抽取了2022例（占总数的5.5%）。十名经过预先培训的医生查阅了相关病历并填写了“特制”问卷。
共查阅了1960份病历（占目标病历的97%）。数据记录的组织和结构差异很大。在不同疾病的各个项目中发现了重要差异：存在病史记录的比例为98.1%（范围：乳房手术为95.6%，AMI为100%）；存在体格检查的比例为92.7%（范围：乳房手术为88.1%，AMI为98.5%），每日病历的完整性在70.8%的病例中良好（范围：肺炎为34.2%，脑血管疾病为93.9%）。还观察到不同类型医院之间存在差异，教学医院和一些私立医院更为准确。
病历质量在不同类型医院和不同疾病之间存在差异。应优先采取提高质量的行动。必须在重组病历、制定指南和培训护理人员方面做出努力。基于计算机的健康信息系统的开发和应用应有助于解决这些问题。
