PMID- 29297865
OWN - NLM
STAT- MEDLINE
DCOM- 20180820
LR  - 20180820
IS  - 2384-8553 (Electronic)
IS  - 0021-2571 (Linking)
VI  - 53
IP  - 4
DP  - 2017 Oct-Dec
TI  - Using health care audit to improve quality of clinical records: the preliminary 
      experience of an Italian Cancer Institute.
PG  - 337-343
LID - 10.4415/ANN_17_04_11 [doi]
AB  - INTRODUCTION: Audit and feedback are recognized as part of a strategy for 
      improving performance and supporting quality and safety in European health care 
      systems. These considerations led the Clinical Management Staff of the "Regina 
      Elena" Italian Cancer Institute to start a project of self-assessment of the 
      quality of clinical records and organizational appropriateness through a 
      retrospective review. MATERIALS AND METHODS: The evaluation about appropriateness 
      and congruity concerned both clinical records of 2013 and of 2015. At the end of 
      the assessment of clinical records of each Care Unit, results were shared with 
      medical staff in scheduled audit meetings. RESULTS: One hundred and thirteen 
      clinical records (19%) did not meet congruity criteria, while 74 (12.6%) resulted 
      as inappropriate. Considering the economic esteem calculated from the difference 
      between Diagnosis Related Groups (DRG) primarily identified as main diagnosis and 
      main surgical intervention or procedure and those modified during the Local 
      Health Unit (LHU) assessment, 2 surgical Care Units produced a high negative 
      difference in terms of economic value with a consequent drop of hospital 
      discharge form (named in Italian "scheda di dimissione ospedaliera", SDO) 
      remuneration, 7 Care Units 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 SDO remuneration. Concerning the quality assessment of 
      clinical records of 2015, the most critical areas were related to medical 
      documents and hospital discharge form compilation. CONCLUSIONS: Our experience 
      showed the effectiveness of clinical audit in assessing the quality of filling in 
      medical records and the appropriateness of hospital admissions and the 
      acceptability of this tool by clinicians.
FAU - Cadeddu, Chiara
AU  - Cadeddu C
AD  - Segreteria Scientifica di Presidenza, Istituto Superiore di Sanita, Rome, Italy.
FAU - Specchia, Maria Lucia
AU  - Specchia ML
AD  - Istituto di Sanita Pubblica, Universita Cattolica del Sacro Cuore, Rome, Italy.
FAU - Cacciatore, Pasquale
AU  - Cacciatore P
AD  - Istituto di Sanita Pubblica, Universita Cattolica del Sacro Cuore, Rome, Italy.
FAU - Marchini, Raffaele
AU  - Marchini R
AD  - Direzione Sanitaria, IRCCS Istituto Nazionale Tumori "Regina Elena", Rome, Italy.
FAU - Ricciardi, Walter
AU  - Ricciardi W
AD  - President, Istituto Superiore di Sanita, Rome, Italy.
FAU - Cavuto, Costanza
AU  - Cavuto C
AD  - Direzione Sanitaria, Ospedale San Giovanni Calibita Fatebenefratelli, Rome, 
      Italy.
LA  - eng
PT  - Journal Article
PL  - Italy
TA  - Ann Ist Super Sanita
JT  - Annali dell'Istituto superiore di sanita
JID - 7502520
SB  - IM
MH  - Cancer Care Facilities/*standards
MH  - Humans
MH  - Italy
MH  - *Medical Audit
MH  - Medical Records/*standards
MH  - Neoplasms/diagnosis/*therapy
MH  - Quality Improvement
MH  - Retrospective Studies
EDAT- 2018/01/04 06:00
MHDA- 2018/08/21 06:00
CRDT- 2018/01/04 06:00
PHST- 2018/01/04 06:00 [entrez]
PHST- 2018/01/04 06:00 [pubmed]
PHST- 2018/08/21 06:00 [medline]
AID - 10.4415/ANN_17_04_11 [doi]
PST - ppublish
SO  - Ann Ist Super Sanita. 2017 Oct-Dec;53(4):337-343. doi: 10.4415/ANN_17_04_11.