Can medical files be used to audit hospital health care? Results of a regional audit of hospital file quality

Objective: The clinical audit method based on a retrospective analysis of medical files can be used to assess hospital health care. The reliability of the results obtained depends on the validity of the data in the file and its completeness. The aim of this work was to assess the quality of this information source.

Methods: The simplified ANDEM/ANAES from was proposed to 47 medical information departments of public and private hospitals participating in the public health care service in the Provence-Alples-Côte d'Azur region. The audit was conducted on a sample of hospital stays during a regular 6-month quality control assessment of hospital health care activity.

Results: Analysis of the 467 forms returned by 39 hospitals, showed that the quality of medical file recordings should be improved as a large amount of data or important documents were missing: reason for hospitalization (recorded on 74.1% of files), operation report (found in 83.2% of files) and discharge summary (found in 66.6% of files).

Conclusions: Clinical audits would be compromised in certain hospitals by the use of medical files. Efforts to improve the quality of hospital medical files should be a priority.