THE MULTIPURPOSE SURVEILLANCE-ORIENTED MEDICAL RECORD - A TOOL FOR QUALITY OF CARE MANAGEMENT

Medical records were oriented towards quality of care surveillance by adding dedicated sections to the progress notes in which to list admis sion problems, medical interventions and adverse events (AEs), Two typ es of simple code were used: indication codes, which identify the indi cation for any given medical intervention; and attribution codes, whic h indicate the causes of any AE. During the first 6 months (302 patien ts), 24 AEs were attributed to drugs, three to procedures, and 42 were unexplained, The incidence of 7.9 suspected adverse drug reactions pe r 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 fo r 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 us eful screens for the identification of potential problems.