[Quality indicator survey of anaesthesia records in hospitals of Aquitaine]. / Indicateur de tenue du dossier anesthésique dans les établissements de santé d'Aquitaine.

OBJECTIVES: Assessing the quality of anaesthesia records according to the criteria of the reference frame of professional practices evaluation proposed by the French Anaesthetists College (Cfar) in 2005. STUDY DESIGN: Retrospective, multicentric study. MATERIALS AND METHODS: Fifty anaesthesia records were randomly selected from each of the 64 health care settings in Aquitaine with an inpatient surgery activity. Survey sampling was based on hospital stays longer than 24h occurring during the second half of 2005 and including a surgical procedure under anaesthesia, excepting local anaesthesia or regional analgesia for labour and delivery. Information regarding the 10 evaluation criteria defined by the Cfar and the French National Authority for Health were gathered. For each setting, the mean completion of the 50 records was rated by a global indicator defined by the number of criteria in conformity divided by the number of relevant criteria. RESULTS: Three thousand one hundred and ninety-three anaesthetic files were screened. The completion of criteria varied between 1 and 92% with a wide dispersion for some criteria according to settings. Completions of airway assessment, preanaesthetic visit and perianaesthetic incidents/accidents were lower than 50%. The median conformity rate of the global indicator was 57%. CONCLUSION: This study brings information concerning the clinical relevance of anaesthesia records and preoperative evaluation practices.

[Access to medical records: who asks and why?]. / Accès au dossier médical: caractéristiques et motifs des demandeurs.

OBJECTIVE: The aim of the survey was to study the characteristics of patients who (or whose families) request access to their medical records, their satisfaction with the handling of their requests, and the reasons for them. METHODS: This prospective study analyzed all the requests for access to medical records sent to two hospitals and collected data from the hospitals at that time (characteristics of the requester, patient and hospitalization) and from the requesters afterwards (opinion survey). RESULTS: The study reviewed 94 requests for medical records. Delays in providing the records exceeded the statutory periods. Most requests were intended to allow continuity of care, to provide information the patient did not receive during hospitalization, or because the patient needed to transmit it to a third party (new doctor, insurance, attorney, worker compensation). The hospitals mailed records to patients by regular mail in 90% of cases. One third of the patients were not satisfied by the handling of their request, complaining about the following difficulties: length of wait for records, complexity of the request procedure, its expense, absence of some documents, and difficulty in understanding the files without medical assistance. CONCLUSION: Improvements are needed, both to decrease the number of requests and to improve the requesters' satisfaction. Specific improvements are suggested.