Using health care audit to improve quality of clinical records: the preliminary experience of an Italian Cancer Institute

Abstract

Introduction: Audit and feedback are recognized as part of a strategy for improving performance and supporting quality and safety in European health care systems. These considerations lead the Clinical Management Staff of an Italian Cancer Institute to start a project of self-assessment of the quality of clinical records and organizational appropriateness through a retrospective review. Materials and methods: The evaluation about appropriateness and congruity concerned both clinical records of 2013 and of 2015. At the end of the assessment of clinical records of each Care Unit, results were shared with medical staff in scheduled audit meetings. Results: One hundred and thirteen clinical records (19%) did not meet congruity criteria, while 74 (12,6%) resulted as inappropriate. Two surgical Care Units produced a high negative difference in terms of economic value, 7 Care Units produced about the same medium difference and 2 Care Units had a positive difference. Concerning the quality assessment of clinical records of 2015, the most critical areas were related to medical documents and Hospital Discharge Form compilation. Conclusions: Our experience showed the effectiveness of clinical audit in assessing the quality of filling in medical records and the appropriateness of hospital admissions and the acceptability of this tool by clinicians.