title: To measure, evaluate and improve: four years long health records self-control activity at G. Pini Orthopedics Institute.
abstract: BACKGROUND
  A health record, when properly handled, can be considered in all respects as an important tool that tracks the course of hospitalization, clinical aspects and the commitment of resources employed in the execution of the episode itself.
  
  
  METHODS
  Lombardy Region has established, since 2009, that each hospital carry out a self-assessment of their documentation. The objective of self-control is to monitor the completeness and accuracy of documentation and to highlight the congruence in order to implement corrective activities to reduce the inappropriateness.
  
  
  RESULTS
  The four years of self-control activities carried out in our Institute show that following the implementation of a supervisory and monitoring system, it was possible to report a statistically significant difference between the percentage of records deemed to comply in the first survey year (2009) and the last year considered (2012). It passes, that is, from 2.9% of conforming clinical records to 68.8% that do not conform.
  
  
  CONCLUSIONS
  This trend is suggestive in confirming, as a whole, the effectiveness of internal controls, structured and repeated over time, which evaluate the completeness of the documentation and generate the appropriate corrective actions.
authors.affiliation: Phd Program in Public Health, University of Milan - Post graduated School in Public Health, University of Milan.
authors.forename: M
authors.initials: M
authors.lastname: Nobile
authors.affiliation: Post graduated School in Public Health, University of Milan.
authors.forename: G
authors.initials: G
authors.lastname: Domeniconi
authors.affiliation: Orthopedic Institute, G. Pini, Milan.
authors.forename: F
authors.initials: F
authors.lastname: Uboldi
authors.affiliation: Post graduated School in Public Health, University of Milan.
authors.forename: C
authors.initials: C
authors.lastname: Conti
authors.affiliation: Post graduated School in Public Health, University of Milan.
authors.forename: N A
authors.initials: NA
authors.lastname: Buccino
authors.affiliation: Department of Biomedical Sciences for Health, University of Milan.
authors.forename: F
authors.initials: F
authors.lastname: Auxilia
authors.affiliation: Post graduated School in Public Health, University of Milan.
authors.forename: P
authors.initials: P
authors.lastname: Navone
mesh_terms: D003625:Data Collection; D004282:Documentation / Q000592:standards*; D006751:Hospital Information Systems / Q000592:standards*; D006760:Hospitalization; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D009985:Orthopedics / Q000592:standards
keywords: completeness; health record; medical record; self-control