A surveillance-oriented medical record as a source of data for both drug and quality of care surveillance

The medical record for hospitalized patients has been modified in order to orient it towards two types of surveillance: adverse drug reactions (ADRs) and the quality of medical care. The modification consists of an adaptation of the progress notes; the transfer of the information to a special databa se is facilitated by the use of a simple system of codes that identify and correlate the items necessary for surveillance purposes. During the 6 month s of observation of the 1103 pediatric patients included in the study, 35 c linically important suspected ADRs were noted by physicians. For the qualit y of medical care surveillance, all drug prescriptions were evaluated and a reas in which to intervene in order to improve the appropriateness of presc riptions were identified. Quality surveillance was also extended to the mon itoring of 'unexplained' adverse events for which no particular cause was a ttributable. We consider it advantageous to carry out these two types of su rveillance simultaneously because they require many common items of informa tion. The use of an oriented medical record as a source of data makes it po ssible to integrate surveillance with everyday ward activities. Copyright ( C) 1999 John Wiley & Sons, Ltd.