[The clinical record as a document of total quality system: a practical example].
Recent analyses indicate that the ratio between total insurance policies paid out and those for damages for malpractice are 1:3. Bad organization of clinical records by doctors is among the main causes of this phenomenon. In fact, clinical records can be considered a public document as well as a means of verifying quality controls. Having precise procedures for the management of clinical records can be useful to demonstrate objectivity both in diagnosis and treatment choice--which can be very important in court cases. This paper illustrates some practical proposals for a correct organization and administration of clinical records.
Pasini
Evasio
E
Qualitá Federazione Società Medico-Scientifiche.
Ravizza
Pier Franco
PF
D005568:Forms and Records Control; D006801:Humans; D008318:Malpractice; D008499:Medical Records / Q000331:legislation & jurisprudence / Q000592:standards; D017749:Total Quality Management / Q000331:legislation & jurisprudence / Q000458:organization & administration*