[Quality of the clinical reports: observational study in Sassari].
Within the program of clinical risk management, and in particular in the phase of the "knowledge" of company reality, the work deals with the topic of the case history in Sassari' local health authority. A study is treated where, on a sample of about 400 cases history, four definite aspects are considered, in particular those that are regarded as the most important in the risk management and about medical responsability: 1) formal consent; 2) daily clinical allowance; 3) therapeutic card; 4) operating card. The results we got show the presence of a formal consent filled in correctly in 36 cases (9%), completed a daily allowance in 36 cases (9%), therapeutic card in 14 (3.5%) cases, operation card in 21 cases (19% su 116 surgical cases). These data, that have permitted to estimate the specific company reality as from pointed out critical states, show the necessity of working, with involvement of professional doctors, to build a history case model with clear and shared rules where you can clearly find the clinical path of a patient, where everything made is quoted and easily readable when necessary.
Virdis
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Azienda Ospedaliera-Universitaria di Sassari. avirdis@aousassari.it
Licheri
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Ruiu
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D000368:Aged; D006801:Humans; D007258:Informed Consent / Q000592:standards*; D007558:Italy; D008487:Medical History Taking; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D019370:Observation; D018579:Patient Selection; D012308:Risk Management; D012494:Sampling Studies; D012941:Social Responsibility