Abstract
Introduction. The aim of this study was to evaluate the quality of the MR compilation in some Operative Units of the ?Azienda Ospedaliera Universitaria - II Università di Napoli? (AOU- SUN) - Italy, before and after an intervention of quality improve- ment, underlining the potential differences in the behaviour of dif- ferent specialists (physicians vs. surgeons).
Methods. Two random samples of 660 MRs were reviewed. A four-step program was developed: 1) first assessment of the MR; 2) implementation of the MR quality, sending a letter with the purpose of the study, the results obtained in the first step from that ward, the guidelines to correctly fill out the MR; 3) follow-up step four months later; 4) comparison of the data before and after the distribution of the guidelines using indicators of completeness of all sections of MR, clarity of handwriting and presence and clar- ity of signature. Results. The main concerns were related to the signature of the duty physician (present in 2.0% and legible in only 15.4%), the presence of the letter of discharge (18.0%) and the clarity of the days of hospital stay (32.0%). After the intervention the improvement of the quality of compilation was modest and regarded mainly medical rather than surgical wards.
Discussion and conclusions. The improvement was not satisfying since from a medical and a legal point of view the indicators should reach 100% of clarity and completeness. A further study is being carried out to improve the involvement of health care professional, so that such requirements will be perceived as a common goal, not as mere bureaucratic initiatives.
