ArticleJournal of preventive medicine and hygiene2019
Quality improvement of medical records through internal auditing: a comparative analysis.
Article in Journal of preventive medicine and hygiene, 2019. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 17 papers.
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Who cites it
17 citing papers in PubMed.
- Balancing peri-operative anaesthesia: Financial efficiency and quality surgical outcomes.Indian journal of anaesthesia · 2026Article
- Impact of a nurse anesthetist student-led training program on perioperative pain management in total knee replacement: A prospective before and after study.International journal of nursing studies advances · 2026Article
- The development and evaluation of the Patient-Controlled Admission Fidelity Checklist.Frontiers in psychiatry · 2026Article
- Evaluating Improvement in the Documentation of Patient Progress Notes Through the BSOAP Framework: A Clinical Audit.Cureus · 2025Article
- CRABEL Score Assessment for Oral Surgery Excision Biopsy Case Notes of Oral Squamous Cell Carcinoma.Cureus · 2024Article
- A Hospital Medical Record Quality Scoring Tool (MeReQ): Development, Validation, and Results of a Pilot Study.Healthcare (Basel, Switzerland) · 2024Article
- A Closed-Loop Clinical Audit of Surgical Documentation of Inpatient Records at a Tertiary Level Hospital in Egypt.Cureus · 2023Article
- Content validation of an instrument for medical record audits.Revista brasileira de enfermagem · 2023Article
- Commentary: Internal audit for assessment and improvement of quality of medical records.Indian journal of ophthalmology · 2022Article
- Initiative to improve quality of paediatric ward-round documentation by application of 'SOAP' format.BMJ open quality · 2022Article
- Audit of documentation accompanying referred maternity cases to a referral hospital in northern Ghana: a mixed-methods study.BMC health services research · 2022Article
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- Establishment and implementation of safety check project for invasive procedures outside the operating room.International journal of nursing sciences · 2021Article
- Evolving Outcome of Acute Myocardial Infarctions in Five Brazilian Geographic Regions Over Two Decades.Arquivos brasileiros de cardiologia · 2020Article
- Assessment of the Quality of Medical Record Documentation using the CRABEL Score Method in a Tertiary Care Hospital in Eastern India.Journal of pharmacy & bioallied sciencesArticle
- Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis.SAGE open nursingReview
Corrections and comments
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Authors and funding
6 authors.
Funding
No grant is acknowledged in the PubMed record.
Abstract
introductionThe systematic evaluation of the quality of medical records is crucial. Nevertheless, even if the improvement of medical records quality represents a priority for every health organization, it might be difficult to realize.This is the first study to assess the efficacy of internal audit as a tool to improve the quality of medical records in hospital setting.
methodsThe program was carried out in a third level teaching hospital. Trained ad hoc evaluation teams carried out two retrospective assessments of quality of medical records using a random sampling strategy. The quality assessment was performed using a 48-items evaluation grid divided into 9 domains: General; Patient Medical History and Physical Examination; Daily Clinical Progress Notes; Daily Nursing Progress Notes; Drug Therapy Chart; Pain Chart; Discharge Summary; Surgery Register; Informed Consent. After the first evaluation of 1.460 medical records, an audit departmental program was set up. The second evaluation was carried out after the internal auditing for 1.402 medical records.
resultsCompared to the first analysis, a significant quality amelioration in all the sections of the medical chart was shown with the second analysis, with an increase of all the scores above 50%. The differences found for each section of medical records between the first and second analysis are all significant (p<0.01).
conclusionsInternal audits are not just measurement activities but a necessary activity to support the organization in achieving its objectives and assessing the quality of clinical care and maintaining high quality professional performance.
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