标题：Using health care audit to improve quality of clinical records: the preliminary experience of an Italian Cancer Institute Chiara Cadeddu, Maria Lucia Specchia, Pasquale Cacciatore, Raffaele Marchini, Walter Ricciardi and Costanza Cavuto
摘要：Introduction. Audit and feedback are recognized as part of a strategy for improvingperformance and supporting quality and safety in European health care systems. Theseconsiderations led the Clinical Management Staff of the “Regina Elena” Italian CancerInstitute to start a project of self-assessment of the quality of clinical records and organizationalappropriateness through a retrospective review.Materials and Methods. The evaluation about appropriateness and congruity concernedboth clinical records of 2013 and of 2015. At the end of the assessment of clinicalrecords of each Care Unit, results were shared with medical staff in scheduled auditmeetings.Results. One hundred and thirteen clinical records (19%) did not meet congruity criteria,while 74 (12.6%) resulted as inappropriate. Considering the economic esteem calculatedfrom the difference between Diagnosis Related Groups (DRG) primarily identified asmain diagnosis and main surgical intervention or procedure and those modified duringthe Local Health Unit (LHU) assessment, 2 surgical Care Units produced a high negativedifference in terms of economic value with a consequent drop of hospital dischargeform (named in Italian “scheda di dimissione ospedaliera”, SDO) remuneration, 7 CareUnits produced about the same medium difference with almost no change as SDO remuneration,and 2 Care Units had a positive difference with a profit in terms of SDOremuneration. Concerning the quality assessment of clinical records of 2015, the mostcritical areas were related to medical documents and hospital discharge form compilation.Conclusions. Our experience showed the effectiveness of clinical audit in assessing thequality of filling in medical records and the appropriateness of hospital admissions andthe acceptability of this tool by clinicians.
