[Integrated medical records for surgical services: a new tool for a new hospital model]. / La cartella clinica integrata per l'area chirurgica: un nuovo strumento di lavoro per un nuovo modello di ospedale.

According to a modern definition, the patient's medical record is a tool shared by health-care professionals whose purpose is to support the planning, providing and documenting of patient-centred care. The requirements and regulations of medical records, which date back to the sixties, need now be adapted to more recent organisational models based on different levels of care intensity and strongly integrated patient-oriented care approaches designed to create connectivity, alignment and collaboration within and between different professional fields. On this basis, the SS. Cosma and Damiano Hospital Chief Physician endorsed a multiprofessional project providing for the complete reorganisation of surgical activities according to the above-mentioned approach and, at the same time, for the elaboration of an "integrated" medical record, capable of overcoming the traditional separation between medical and nursing documents. This paper presents the results of a long period of complex teamwork consisting in revising and sharing a new medical record model based on principles of professional integration and patient-centredness in health-care provision.

[Quality assurance of hospital medical records as a risk management tool]. / Analisi di qualità della Cartella Clinica come strumento del Risk management.

A retrospective analysis of hospital medical records was performed jointly by the Medicolegal department of the Pistoia Local Health Unit N. 3 and by the management of the SS. Cosma and Damiano di Pescia Hospital. Evaluation was based on ANDEM criteria, JCAHO standards, and the 1992 discharge abstract guidelines of the Italian Health Ministry. In the first phase of the study, data were collected and processed for each hospital ward and then discussed with clinicians and audited. After auditing, appropriate actions were agreed upon for correcting identified problems. Approximately one year later a second smaller sample of medical records was evaluated and a higher compliance rate with the established corrective actions was found in all wards for all data categories. In this study the evaluation of medical records can be considered in the wider context of risk management, a multidisciplinary process directed towards identifying and monitoring risk through the use of appropriate quality indicators.

[Evaluation of the appropriateness of prescribing non-invasive cardiologic tests]. / La valutazione dell'appropriatezza della prescrizione dei test cardiologici non invasivi.

BACKGROUND: We evaluated the appropriateness of the prescription of echocardiography, exercise testing, Holter monitoring and vascular sonography for ambulatory patients, performed during 4 weeks in 21 outpatient laboratories in Tuscany and Umbria, Italy. METHODS: We collected the following data: the appropriateness of the prescription (according to the guidelines of the Italian Federation of Cardiology), the prescribing physician (cardiologist vs noncardiologist), the synthetic result (normal vs abnormal) and the clinical utility (useful vs useless) of each exam. RESULTS: We evaluated 5614 prescriptions (patients: 3027 males, 2587 females; mean age 63 years, range 14-96 years). The indication to the test was of class I (appropriate) in 45.3%, of class II (doubtfully appropriate) in 34.8% and of class III (inappropriate) in 19.9% of the cases. The test was abnormal in 58.3% of class I exams vs 17% of class III exams (p < 0.05). The test was useful in 72.4% of class I exams vs 17.1% of class III exams (p < 0.05). The test was prescribed by a cardiologist in 1882 cases (33.5%). Cardiologist-prescribed exams were of class I in 57.3%, of class II in 32.4% and of class III in 10.3% of the cases vs 39.2, 36.1 and 24.7% of non-cardiologist-prescribed exams (p < 0.05). Cardiologist-prescribed exams were abnormal in 53.4% of the cases vs 39% of those of non-cardiologists' (odds ratio 1.76, 95% confidence interval 1.58-1.97; p < 0.05). Cardiologist-prescribed exams were useful in 64.7% of the cases vs 44.4% of those of non-cardiologists' (odds ratio 2.26, 95% confidence interval 2.02-2.53; p < 0.05). CONCLUSIONS: In Tuscany and Umbria, Italy, less than half of the prescriptions for non-invasive diagnostic tests are appropriate: appropriately prescribed exams more often provide abnormal and useful results; cardiologist-prescribed exams are more often appropriate, abnormal and useful.