[Audit on the quality of medical records in oncology at the Lyon civic hospices]

Abstract

Objective: Assess the quality of information contained in the medical files of patients with cancer pathology.

Patients and methods: Eighty medical files from patients cared for in the cancerology units of the Lyons civil hospices were retrospectively analyzed to determine information quality. Prior to the audit, the health care teams established a set of consensus standards to compared with observed procedures. After data collection and analysis of the results, observed departures from the standards led to propositions for guidelines designed to improve points where significant deviations were observed.

Results: For certain items, the medical files did not always contain the expected data. Significant deviations were observed for important data such as postal code of birth, pTNM classification, presence of pathology report, codified evaluation of general status.

Conclusion: Management of these patients requires more rigorous record keeping and classing of appropriate data. A unique data sheet is proposed for all cancer. This should be a computerized sheet with a cancerology reference in each medical unit.