Terranova Giuseppina, Cortesi Elisabetta, Briani Silvia, Giannini Raffaella
U.F.C. Medicina Legale ASL 3 Pistoia.
Ig Sanita Pubbl. 2006 Jul-Aug;62(4):371-85.
A retrospective analysis of hospital medical records was performed jointly by the Medicolegal department of the Pistoia Local Health Unit N. 3 and by the management of the SS. Cosma and Damiano di Pescia Hospital. Evaluation was based on ANDEM criteria, JCAHO standards, and the 1992 discharge abstract guidelines of the Italian Health Ministry. In the first phase of the study, data were collected and processed for each hospital ward and then discussed with clinicians and audited. After auditing, appropriate actions were agreed upon for correcting identified problems. Approximately one year later a second smaller sample of medical records was evaluated and a higher compliance rate with the established corrective actions was found in all wards for all data categories. In this study the evaluation of medical records can be considered in the wider context of risk management, a multidisciplinary process directed towards identifying and monitoring risk through the use of appropriate quality indicators.
皮斯托亚地方卫生单位3的法医学部门与佩夏的圣科斯马和达米亚诺医院管理层联合对医院病历进行了回顾性分析。评估基于ANDEM标准、美国医疗机构评审联合委员会（JCAHO）标准以及意大利卫生部1992年的出院摘要指南。在研究的第一阶段，收集并处理了每个医院病房的数据，然后与临床医生进行讨论并审计。审计后，就纠正已发现问题商定了适当行动。大约一年后，对第二批数量较少的病历样本进行了评估，发现所有病房所有数据类别的既定纠正措施的合规率都更高。在本研究中，病历评估可在风险管理这一更广泛背景下进行考虑，风险管理是一个多学科过程，旨在通过使用适当的质量指标来识别和监测风险。
