caa a22 4500 397519362 CHVBK 20180308164628.0 cr unu---uuuuu 161202e199512 xx s 000 0 eng 10.1093/intqhc/7.4.399 doi (NATIONALLICENCE)oxford-10.1093/intqhc/7.4.399 The Multipurpose Surveillance-oriented Medical Record: A Tool for Quality of Care Management [Elektronische Daten] [ITALO MAISTRELLO, MAURO D. FEBBRARI, MARIO TRAMONTINI, MAURO MAISTRELLO, LAURO NATALE] Medical records were oriented towards quality of care surveillance by adding dedicated sections to the progress notes in which to list admission problems, medical interventions and adverse events (AEs). Two types of simple code were used: indication codes, which identify the indication for any given medical intervention; and attribution codes, which indicate the causes of any AE. During the first 6 months (302 patients), 24 AEs were attributed to drugs, three to procedures, and 42 were unexplained. The incidence of 7.9 suspected adverse drug reactions per 100 patients exceeds that obtained with other hospital-based adverse drug reporting programmes. Unexplained events are kept under constant statistical control to detect possible alerting signals. As a tool for quality of care management, the surveillance-oriented record can be used to monitor the appropriateness of medical interventions, identify "high risk” areas and deduce outcome indicators which constitute useful screens for the identification of potential problems. © 1996 Elsevier Science Ltd Articles nationallicence Medical records nationallicence adverse events nationallicence adverse drug reactions nationallicence quality improvement nationallicence MAISTRELLO ITALO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut FEBBRARI MAURO D. Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut TRAMONTINI MARIO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut MAISTRELLO MAURO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut NATALE LAURO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut International Journal for Quality in Health Care Oxford University Press 7/4(1995-12), 399-405 1353-4505 7:4<399 1995 7 intqhc https://doi.org/10.1093/intqhc/7.4.399 text/html Onlinezugriff via DOI 1 research-article jats NATIONALLICENCE 856 40 https://doi.org/10.1093/intqhc/7.4.399 text/html Onlinezugriff via DOI NATIONALLICENCE 700 1- MAISTRELLO ITALO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut NATIONALLICENCE 700 1- FEBBRARI MAURO D. Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut NATIONALLICENCE 700 1- TRAMONTINI MARIO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut NATIONALLICENCE 700 1- MAISTRELLO MAURO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut NATIONALLICENCE 700 1- NATALE LAURO Department of Internal Medicine, Policlinico Ponte San Pietro Hospital Bergamo, Italy aut NATIONALLICENCE 773 0- International Journal for Quality in Health Care Oxford University Press 7/4(1995-12), 399-405 1353-4505 7:4<399 1995 7 intqhc Metadata rights reserved CC BY-NC-4.0 http://creativecommons.org/licenses/by-nc/4.0 nationallicence BK010053 XK010053 XK010000 NATIONALLICENCE NATIONALLICENCE NL-oxford