Quality Assessment of medical records as a tool for Clinical Risk Management: A three year experience of a Teaching Hospital Policlinico Umberto I, Rome

Abstract

Introduction: The medical record was defined by the Italian Ministry of Health in 1992 as "the information tool designed to record
all relevant demographic and clinical information on a patient during a single hospitalization episode". Retrospective analysis of
medical records is a tool for selecting direct and indirect indicators of critical issues (organizational, management and technical).
The project’s aim being the promotion of an evaluation and self-evaluation process of medical records as a Clinical Risk
Management tool to improve the quality of care within hospitals.
Methods: The Authors have retrospectively analysed, using a validated grid, 1,184 medical records of patients admitted to the
Teaching Hospital “Umberto I” in Rome during a three-year period (2013-2015). Statistical analysis was performed using SPSS
for Windows © 19:00. All duly filled out criteria (92) were examined. “Strengths” and "Weaknesses" were identified through data
analysis and Best and Bad Practice were identified based on established criteria.
Conclusion: The data analysis showed marked improvements (statistically significant) in the quality of evaluated clinical
documentation and indirectly upon behaviour. However, when examining some sub-criteria, critical issues emerge; these could be
subject to future further corrective action.