[Evaluation of the quality of hospital medical records in a hospital in Turin (Italy)].
The San Giovanni Battista Hospital in Turin validated a tool for evaluating the quality of hospital patient records. The tool defines the essential contents of patient records, indicators and weights as well as the standard score that must be reached. A pilot study was performed in 2007 to evaluate whether this tool adequately evaluates the quality of hospital patient records in both medical and surgical wards, and whether it can do so in a standardized and repeatable manner. A random sample of 206 medical charts of patients admitted to the San Giovanni Battista Hospital in 2007 was extracted and analysed. The instrument was found to adequately evaluate hospital patient records in a standardisd and repeatable manner.
Gianino
Maria Michela
MM
Dipartimento di Sanità Pubblica - Università degli studi di Torino. mariola.gianino@unito.it
Raciti
Ida Marina
IM
Galzerano
Mario
M
Villata
Eugenia
E
Fonte
Gianfranco
G
Rapellino
Marco
M
Fiandra
Umberto
U
D005568:Forms and Records Control; D006748:Hospital Departments; D006786:Hospitals, Urban / Q000706:statistics & numerical data*; D006801:Humans; D007258:Informed Consent; D007558:Italy; D008487:Medical History Taking / Q000592:standards; D008499:Medical Records / Q000592:standards* / Q000706:statistics & numerical data; D008500:Medical Records Department, Hospital / Q000592:standards*; D010865:Pilot Projects; D011785:Quality Assurance, Health Care / Q000379:methods*; D012189:Retrospective Studies; D012494:Sampling Studies