QUALITY OF THE RECORD OF PATIENT ASSESSMENT IN GERIATRIC UNITS - CONTRIBUTION OF A STRUCTURED MEDICAL RECORD

OBJECTIVES: The medical record (MR) is a key document for hospitalized patients. Several audits have however demonstrated that much importan t information is often missing in hospital MR We conducted this survey with the aim of improving the quality of MR in a geriatric unit PATIE NTS AND METHODS: A structured MR was elaborated and implemented in ord er to guide and record the assessment of patients admitted in our geri atric ward. MR of 54 consecutive patients admitted after implementatio n of the structured MR were studied and compared to those of 108 conse cutive patients admitted on the preceeding year (classical MR). Qualit y of data collected at admission was assessed using a 33-item guide, p roposed by 3 experts in geriatric medicine unaware of the structured M R studies. For each item, a binary score (present/ absent) and a preci sion score were used. A validation study was conducted using the same methods in another geriatric ward which has not participated to develo pment of the structured charts MR studied. RESULTS: For most items stu died, information was present in a significantly higher proportion in structured MR than in classical MR Likewise, the precision score was s ignificantly higher in structured MR. The validation survey found anal ogous results. CONCLUSION: Use of a structured MR significantly improv es the quality of data collection at admission in geriatric units. Thi s improvement appears to be related more to the use of the structured MR than the effect of developping a new tool.