[A method for auditing medical records quality: audit of 467 medical records within the framework of the medical information systems project quality control].
Future hospital accreditation could take into account the quality of medical files. The objectives of this study is to test a method for auditing and evaluating the quality of the handing of medical files. We conducted a retrospective regional audit based on the frame of reference the National Agency for Medical Development and Evaluation, by using a sample of cases, stratified by establishment. In our region, the global budgets of 47 public and private hospitals participating in the public hospital service, are adjusted while keeping in mind the medicalised activity data (PMSI). This audit was proposed to the doctors of the Department of Medical Information on the occasion of the regulatory PMSI quality control. A total of 467 questionnaires were given by 39 of the 47 sollicited hospitals (83%). The methodological aspects (questionnaire, cooperative approach...) are discussed. The make-up of medical files can alos be improved by raising the percentage of the presence of important data or documents such as the reason for admission (74.1%), the surgery report (83.2%), and the hospitalisation report (66.6%). A system for classifying the paraclinical results is shared and systematic throughout the service or hospital in only 73.2% of cases. The quality of the handing of medical files seems problematic in our hospitals and actions for improving the quality should be undertaken as a priority.
Unité de Santé Publique et d'information Médicale (USPIM), Faculté de Médecine de Nice.
F
F
Boulay
T
T
Chevallier
Y
Y
Gendreike
V
V
Mailland
Y
Y
Joliot
R
R
Sambuc
D000068:Accreditation; D005602:France; D006302:Health Services Research; D016304:Hospitals, Private / Q000592:standards; D006779:Hospitals, Public / Q000592:standards; D006801:Humans; D008485:Medical Audit / Q000379:methods*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D008505:Medical Staff, Hospital; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D012189:Retrospective Studies; D011795:Surveys and Questionnaires