[The clinical record as a document of total quality system: a practical example]

Ital Heart J Suppl. 2004 Feb;5(2):112-8.
[Article in Italian]

Abstract

Recent analyses indicate that the ratio between total insurance policies paid out and those for damages for malpractice are 1:3. Bad organization of clinical records by doctors is among the main causes of this phenomenon. In fact, clinical records can be considered a public document as well as a means of verifying quality controls. Having precise procedures for the management of clinical records can be useful to demonstrate objectivity both in diagnosis and treatment choice--which can be very important in court cases. This paper illustrates some practical proposals for a correct organization and administration of clinical records.

Publication types

  • English Abstract
  • Review

MeSH terms

  • Forms and Records Control
  • Humans
  • Malpractice
  • Medical Records* / legislation & jurisprudence
  • Medical Records* / standards
  • Total Quality Management / legislation & jurisprudence
  • Total Quality Management / organization & administration*