title: Quality improvement of medical records in a teaching hospital.
abstract: BACKGROUND
  The aim of this study was to evaluate the quality of the MR compilation in some Operative Units of the "Azienda Ospedaliera Universitaria--II Università di Napoli" (AOU- SUN)-Italy, before and after an intervention of quality improvement, underlining the potential differences in the behaviour of different specialists (physicians vs. surgeons).
  
  
  METHODS
  Two random samples of 660 MRs were reviewed. A four-step program was developed: (1) first assessment of the MR; (2) implementation of the MR quality, sending a letter with the purpose of the study, the results obtained in the first step from that ward, the guidelines to correctly fill out the MR; (3) follow-up step four months later; (4) comparison of the data before and after the distribution of the guidelines using indicators of completeness of all sections of MR, clarity of handwriting and presence and clarity of signature.
  
  
  RESULTS
  The main concerns were related to the signature of the duty physician (present in 2.0% and legible in only 15.4%), the presence of the letter of discharge (18.0%) and the clarity of the days of hospital stay (32.0%). After the intervention the improvement of the quality of compilation was modest and regarded mainly medical rather than surgical wards.
  
  
  CONCLUSIONS
  The improvement was not satisfying since from a medical and a legal point of view the indicators should reach 100% of clarity and completeness. A further study is being carried out to improve the involvement of health care professional, so that such requirements will be perceived as a common goal, not as mere bureaucratic initiatives.
authors.affiliation: Postgraduate School in Hygiene and Preventive Medicine, II University of Naples, Italy. francesco.attena@unina2.it
authors.forename: F
authors.initials: F
authors.lastname: Attena
authors.forename: M A
authors.initials: MA
authors.lastname: Di Palma
authors.forename: S
authors.initials: S
authors.lastname: Esposito
authors.forename: V
authors.initials: V
authors.lastname: Galdo
authors.forename: A
authors.initials: A
authors.lastname: Gimigliano
authors.forename: C
authors.initials: C
authors.lastname: Parmeggiani
authors.forename: E
authors.initials: E
authors.lastname: Agozzino
mesh_terms: D005500:Follow-Up Studies; D006284:Health Plan Implementation / Q000458:organization & administration; D006740:Hospital Administrators / Q000458:organization & administration; D006784:Hospitals, Teaching / Q000458:organization & administration*; D006801:Humans; D007558:Italy; D008499:Medical Records / Q000592:standards*; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care / Q000458:organization & administration*; D058996:Quality Improvement / Q000458:organization & administration*