A randomised controlled intervention to improve quality of medical records

BACKGROUND The aim of this study was to evaluate the quality of the medical records (MRs) compilation in the Teaching Hospital of the Second University of Naples, after a controlled intervention of quality improvement. METHODS From the 66 wards of the Teaching Hospital, we selected, 8 homogeneous pairs of wards, matched for similar typology. For each pair we randomized a ward to be submitted to a training course about correct compilation of MRs (treated group), considering the other ward as a control (no treated group). These sections of MR were evaluated: patient identity, patient’s history, physical examination, daily diary, patient chart and letter of discharge. For each section we evaluated the completeness (complete/uncomplete section) and the clarity (clear/unclear handwriting). RESULTS In general, the worst result in both groups was the absence of signature in the daily diary (76.6% in treated group and 94.4% in no treated group). Instead, the widest differences between the two groups has been detected in the compilation of the daily diary [absent/incomplete only in the 1.9%, respect to the 21.9% of the no treated group (RR=11; C.I.=5.1-26.4)] and the physical examination [absent/incomplete in the 2.8% of the treated group and in 21.3% of no treated group (RR=7.5; C.I.=3.8-14.8)]. CONCLUSION The comparison between treated and no treated group shows that there are a significant improvement in the treated group about medical record compilation, nevertheless the results obtained were not totally satisfactory because there was a scarce quality of medical records compilation in both groups