[The quality of medical records: a retrospective study in Lazio Region, Italy]. / La qualità della cartella clinica negli ospedali del Lazio.

INTRODUCTION: Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice. PURPOSE: We performed a retrospective study in order to assess the quality of medical records in the Lazio region. METHODS: From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires. RESULTS: A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items: presence of anamnesis 98.1% (range: from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range: from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range: from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate. CONCLUSIONS: Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.

Occupation, asthma, and chronic respiratory symptoms in a community sample of older women.

We evaluated the role of occupational factors on the prevalence of self-reported asthma, chronic bronchitis, and asthma-like respiratory symptoms among women >= 55 yr. Occupational history, smoking, and respiratory conditions were collected through an interviewer-administered questionnaire from 1,226 women. Lung function data from 820 subjects were used for group "validation" of the outcome variables. Significant associations were observed between the respiratory conditions and occupational groupings based on the longest occupation held. Artists, writers, decorators, and photographers (odds ratio [OR] = 3.1), and women in service occupations (OR = 2.4) had a significantly increased risk of asthma. The odds of asthma-like symptoms was significantly elevated among nurses and other nonphysician health workers (OR = 2.9), social workers (OR = 2.9), and homemakers (OR = 2.4). Exposure to dusts, gas, vapors, fumes, or sensitizers was associated with a significantly increased odds of asthma (OR = 1.8) and with a marginally significant increased odds of asthma-like symptoms (OR = 1.4). Smoking accounted for a large proportion of asthma and asthma-like conditions in this population (population attributable risk [PAR] = 40.5% and 35.0%, respectively); employment in occupations with a high probability of exposures to dusts, gas, vapors, fumes, or sensitizers also contributed significantly to the burden of asthma (PAR = 15.1 to 20.0%) and asthma-like symptoms (PAR = 7.5 to 10.2%).