Agozzino E, Esposito S, Parmeggiani C, Piro A, Grippo N, Di Palma M A
Dipartimento di Medicina Clinica Pubblica e Preventiva, Seconda Università degli Studi di Napoli.
Ann Ig. 2008 Jul-Aug;20(4):401-8.
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.
为评估和提高诊所及外科科室病历记录的质量，评估涉及意大利那不勒斯“第二大学医院”的66个手术单元（O.U.）。每个手术单元随机抽取10份病历，共660份。使用数据的完整性、清晰度和可追溯性标准对病历的所有部分进行质量评估。最关键的问题是：几乎所有部分的字迹都不清楚；外科手术中出院小结很少（占17.0%），临床日志中几乎完全没有医生签名（占2.3%）。外科科室病历的完整性（包括患者病史、体格检查、知情同意书）明显更高。诊所科室的病历记录明显更准确。总体而言，病历记录质量较差。这表明需要通过让工作人员认识到正确填写的重要性来提高质量。
