ABSTRACT: In 1999, the Claudius-Regaud Institute of Toulouse, France, specialized in oncology, set up a workshop in order to assess the quality of its patients medical records. A retrospective evaluation was performed on a 100-chart-sample drawn from all the charts in the institution. Results show that the medical records are subdivised into three parts: medical care, nursing care and imaging. Some of the explored charts show a lack of data, and a certain inconsistency in the charts' organization and in the structure of information was reported. Patient's record is a key to communication between the different care providers in oncology. To improve its quality, efforts will have to be done in restructuring the charts, creating guidelines and training the different caregivers.
Bulletin du cancer 09/2001; 88(8):793-803. · 0.67 Impact Factor