Boulay F, Chevallier T, Gendreike Y, Joliot Y, Sambuc R
Département d'Information médicale, Hôpital St Roch, Nice.
Presse Med. 1997 Dec 20;26(40):1962-5.
The clinical audit method based on a retrospective analysis of medical files can be used to assess hospital health care. The reliability of the results obtained depends on the validity of the data in the file and its completeness. The aim of this work was to assess the quality of this information source.
The simplified ANDEM/ANAES from was proposed to 47 medical information departments of public and private hospitals participating in the public health care service in the Provence-Alples-Côte d'Azur region. The audit was conducted on a sample of hospital stays during a regular 6-month quality control assessment of hospital health care activity.
Analysis of the 467 forms returned by 39 hospitals, showed that the quality of medical file recordings should be improved as a large amount of data or important documents were missing: reason for hospitalization (recorded on 74.1% of files), operation report (found in 83.2% of files) and discharge summary (found in 66.6% of files).
Clinical audits would be compromised in certain hospitals by the use of medical files. Efforts to improve the quality of hospital medical files should be a priority.
基于病历回顾性分析的临床审计方法可用于评估医院医疗保健情况。所获结果的可靠性取决于病历数据的有效性及其完整性。本研究旨在评估此信息来源的质量。
向参与普罗旺斯-阿尔卑斯-蓝色海岸地区公共卫生保健服务的47家公立和私立医院的医疗信息部门发放简化版ANDEM/ANAES表格。审计是在对医院医疗保健活动进行常规6个月质量控制评估期间，对一部分住院病例进行的。
对39家医院返回的467份表格进行分析后发现，由于大量数据或重要文件缺失，病历记录质量有待提高：住院原因（74.1%的病历中有记录）、手术报告（83.2%的病历中有）和出院小结（66.6%的病历中有）。
某些医院使用病历进行临床审计可能会受到影响。提高医院病历质量的工作应成为优先事项。
