Evaluation of the quality of medical records in the Monastir regional hospitals--Tunisia
Letaief, M.; Mtiraoui, A.; Mandhouj, O.; Ben Salem, K.; Soltani, M.S.; Bchir, A.
La Tunisie Medicale 81(5): 303-307
2003
ISSN/ISBN: 0041-4131 PMID: 12934450 Document Number: 559112
The aim of this study is to evaluate the quality of medical records throughout a sample of 380 records at the medicine ward of three regional hospitals in Monastir. The medical audit was performed using a reference standard previously developed by foreign teams and adapted to the health care features of our country. The results showed that the quality of medical records should be improved. It depends on the hospital and in 2/3 of cases there was a lack of information or sheets important for the coordination and the continuity of medical care. The quality improvement of medical records could be reached by the professional education, which should emphasise the importance of medical and administrative data in the health care management. This could be included in a continuous quality improvement program.