title: [Medical record management and risk management processes. State of the art and new normative guidelines about the organization and the management of the sanitary documentation in the National Health System or Hospital Trusts].
abstract: Recent health care reforms, the start of accreditation processes of health institutions, and the introduction also in the health system of risk management concepts and instruments, borrowed from the enterprise culture and the emphasis put on the protection of privacy, render evident the need and the urgency to define and to implement improvement processes of the organization and management of the medical documentation in the hospital with the aim of facilitation in fulfilment of regional and local health authorities policies about protection of the safety and improvement of quality of care. Currently the normative context that disciplines the management of medical records inside the hospital appears somewhat fragmentary, incomplete and however not able to clearly orientate health operators with the aim of a correct application of the enforced norms in the respect of the interests of the user and of local health authority. In this job we individuate the critical steps in the various phases of management process of the clinical folder and propose a new model of regulations, with the purpose to improve and to simplify the management processes and the modalities of compilation, conservation and release to entitled people of all clinical documentation.
authors.affiliation: Sistema Epidemiologico Regionale-Regione Veneto. paolo.spolaore@libero.it
authors.forename: P
authors.initials: P
authors.lastname: Spolaore
authors.forename: G
authors.initials: G
authors.lastname: Murolo
authors.forename: M
authors.initials: M
authors.lastname: Sommavilla
mesh_terms: D003219:Confidentiality / Q000331:legislation & jurisprudence; D006779:Hospitals, Public / Q000331:legislation & jurisprudence / Q000458:organization & administration; D006801:Humans; D007558:Italy; D008499:Medical Records / Q000592:standards*; D008500:Medical Records Department, Hospital / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D009313:National Health Programs / Q000331:legislation & jurisprudence / Q000458:organization & administration*; D012308:Risk Management / Q000458:organization & administration*; D013222:State Medicine / Q000331:legislation & jurisprudence / Q000458:organization & administration