PubMed1998
OBJECTIVE: Record keeping contributes to the quality of health care in addition to fulfilling medicolegal and accreditation regulations. We conducted an audit of patient files in 15 public hospitals in Aquitaine to determine their compliance with national laws. METHODS: One hundred patient files were randomly selected in each hospital. Their compliance with 18 criteria established in 1992 by the ANDEM was studied. These 18 criteria were updated in accordance with the latest decrees from the health ministry and precisely defined in order to achieve good reproducibility of the measurements. RESULTS: Ten percent of the files fulfilled all 18 criteria. Each component of the record was correctly identified and the name of the general practitioner, admission documents, and delivery, anesthesia and transfusion records were almost always present. Surgery reports were found in 65 to 89% of the files. Low compliance with three criteria was observed: authorization to give health care to a minor (39 to 80% of the files), identification of the physician who prescribed the drugs during hospitalization (6 to 32%) and discharge prescription (42 to 95%). We also pinpointed problems concerning archiving and retrieval, especially concerning the results of complementary exams which were not necessarily stored with the patient files. CONCLUSION: This audit allowed us to define the first steps of a quality improvement project for patient records. We were able to deduct recommendations for analyzing compliance with legal requirements and suggest that the 1992 ANDEM criteria be updated to allow for valid comparisons between health care establishment.