Improving the quality of medical records

Abstract Background Medical record is an essential tool both in patients’ diagnostic and therapeutic pathways and communication between different care providers. It also has an economic-administrative, medical-legal and epidemiological function. From an economic-administrative point of view, a medical record allows an evaluation and review of services to better manage the corporate health budget. In addition, it allows traceability and complete transparency of the health activities carried out. The study evaluates the formal quality of medical records compiled in an Italian private clinic before and after a training intervention. Methods In June 2019, a retrospective study was carried out to assess a private clinic’s quality of medical records. One month later, healthcare providers were trained on the appropriate compilation of medical records, whose pre-printed format was structurally improved. In March 2020, we verified the quality of medical records produced after that training intervention. Statistical analysis (Wilcoxon test) was carried out through Stata. Results A total of 149 medical records were reviewed. Statistically significant improvements (p < 0,05), between before and after training intervention, were for overall readability (33.3% vs 74.7%), completeness of admission and discharge dates (33.3% vs 74.40%), for completeness of anamnesis (13.6% vs 63.9%), for completeness of therapeutic card (53% vs 85.5%), in the reduction of non-compliance corrections (22.7% vs 4.8%), signature presence of physical examination (34.9% vs 71.1%) and for signature presence in the hospital discharge card (86.4% vs 96.4%). Conclusions The results show that simple measures, such as staff training and restructuring of the format, are effective in improving the quality of medical records. Key messages • Healthcare providers should perceive the proper completion of medical records as a common goal. • Well-completed medical records contribute to better health care.


Background:
Medical record is an essential tool both in patients' diagnostic and therapeutic pathways and communication between different care providers.It also has an economic-administrative, medical-legal and epidemiological function.From an economic-administrative point of view, a medical record allows an evaluation and review of services to better manage the corporate health budget.In addition, it allows traceability and complete transparency of the health activities carried out.
The study evaluates the formal quality of medical records compiled in an Italian private clinic before and after a training intervention.

Methods:
In June 2019, a retrospective study was carried out to assess a private clinic's quality of medical records.One month later, healthcare providers were trained on the appropriate compilation of medical records, whose pre-printed format was structurally improved.In March 2020, we verified the quality of medical records produced after that training intervention.Statistical analysis (Wilcoxon test) was carried out through Stata.

Results:
A total of 149 medical records were reviewed.Statistically significant improvements (p < 0,05), between before and after training intervention, were for overall readability (33.3% vs 74.7%), completeness of admission and discharge dates (33.3% vs 74.40%), for completeness of anamnesis (13.6% vs 63.9%), for completeness of therapeutic card (53% vs 85.5%), in the reduction of non-compliance corrections (22.7% vs 4.8%), 15th European Public Health Conference 2022 Background: Migration of health professionals is one of the key challenges for many healthcare systems.In Poland this phenomenon is still under-researched.The aim of our study was to explore the estimated trends and directions of emigration among Polish health professionals.

Methods:
The research was based on the data analysis of specifying the number of people who applied for the certification of their professional qualifications (the right to practice a profession) at five national registers maintained by chambers of health professionals: 1) doctors and dentists, 2) nurses and midwives, 3) physiotherapists; 4) pharmacists and 5) laboratory diagnosticians.The gathered data reported information which allows for an approximate determination of how many professionals are considering a decision to migrate from Poland.Additionally exploration of data from the European Commission Regulated Profession Database in the EU Single Market was performed.Results: About 7-9% of Polish doctors and nurses have applied for certificates, which confirm their right to practice their profession in other European countries.The number of such certificates applied for by physiotherapists is also worrying.Emigration among pharmacists and laboratory diagnosticians is rather marginal.The biggest number of certificates, was issued to health professionals in the years 2004-2007, right after Poland joined the EU.In the period 2008-2015 the trend was not constant and it was related to the healthcare reform and changes in health professionals' remuneration.Since 2016 the number of health workers applying for the certificates is by to a certain extent falling.The main destination of Polish emigrants were and are: United Kingdom, Germany, Sweden, Spain, Ireland, and EFTA countries (Norway, Switzerland).

Conclusions:
Implementation of a mechanism for monitoring emigration is necessary, but systemic improvement of working conditions in Polish healthcare system is also needed.

Key messages:
The emigration, especially of young generations of medical staff, causes significant problems for the Polish healthcare system.
More in-depth research on migration of health professionals is necessary.
Abstract citation ID: ckac131.375Factors associated with Finnish home care workers job satisfaction

Background:
In Finland, home care is seen as a primary form of care for older people.However, rising numbers of clients with increasingly complex conditions have led to deteriorated working conditions and poor job satisfaction among home care staff.In this study, we examined if greater amount of direct care time, higher team autonomy, number of unique clients, and client's need for care are associated with job satisfaction.