PMID- 8820216
OWN - NLM
STAT- MEDLINE
DCOM- 19961230
LR  - 20190512
IS  - 1353-4505 (Print)
IS  - 1353-4505 (Linking)
VI  - 7
IP  - 4
DP  - 1995 Dec
TI  - The multipurpose surveillance-oriented medical record: a tool for quality of care 
      management.
PG  - 399-405
AB  - Medical records were oriented towards quality of care surveillance by adding 
      dedicated sections to the progress notes in which to list admission problems, 
      medical interventions and adverse events (AEs). Two types of simple code were 
      used: indication codes, which identify the indication for any given medical 
      intervention; and attribution codes, which indicate the causes of any AE. During 
      the first 6 months (302 patients), 24 AEs were attributed to drugs, three to 
      procedures, and 42 were unexplained. The incidence of 7.9 suspected adverse drug 
      reactions per 100 patients exceeds that obtained with other hospital-based 
      adverse drug reporting programmes. Unexplained events are kept under constant 
      statistical control to detect possible alerting signals. As a tool for quality of 
      care management, the surveillance-oriented record can be used to monitor the 
      appropriateness of medical interventions, identify "high risk" areas and deduce 
      outcome indicators which constitute useful screens for the identification of 
      potential problems.
FAU - Maistrello, I
AU  - Maistrello I
AD  - Department of Internal Medicine, Policlinico Ponte, San Pietro Hospital, Bergamo, 
      Italy.
FAU - Febbrari, M D
AU  - Febbrari MD
FAU - Tramontini, M
AU  - Tramontini M
FAU - Maistrello, M
AU  - Maistrello M
FAU - Natale, L
AU  - Natale L
LA  - eng
PT  - Journal Article
PL  - England
TA  - Int J Qual Health Care
JT  - International journal for quality in health care : journal of the International 
      Society for Quality in Health Care
JID - 9434628
SB  - IM
MH  - Drug Monitoring/statistics & numerical data
MH  - Drug-Related Side Effects and Adverse Reactions
MH  - Humans
MH  - Italy
MH  - *Medical Records, Problem-Oriented/statistics & numerical data
MH  - Population Surveillance/*methods
MH  - Quality of Health Care/*organization & administration/statistics & numerical data
MH  - Sensitivity and Specificity
EDAT- 1995/12/01 00:00
MHDA- 1995/12/01 00:01
CRDT- 1995/12/01 00:00
PHST- 1995/12/01 00:00 [pubmed]
PHST- 1995/12/01 00:01 [medline]
PHST- 1995/12/01 00:00 [entrez]
AID - 1353450595000275 [pii]
AID - 10.1093/intqhc/7.4.399 [doi]
PST - ppublish
SO  - Int J Qual Health Care. 1995 Dec;7(4):399-405. doi: 10.1093/intqhc/7.4.399.