[Quality of medical records in oncology: results of an audit of the Lyon Civil Hospices]

Abstract

The objective of this study was to assess the quality of information contained in the medical files of patients in an oncology unit of the Lyons Civil Hospices. Prior to the audit, the health care teams established a set of consensus standards to compare with observed procedures. The analysis of the results led to propositions for guidelines designed to improve points where significant deviations were observed. In the first audit, 80 medical files from patients cared for in four oncology units were retrospectively analysed to determine information quality. Seven items of this audit were retained for a second audit on 127 medical files of patients in a cancerology unit; those items were: postal code of birth place, weight, codified evaluation of general status, TNM classification, pTNM classification, presence of pathology report, localisation of metastasis. Significant deviations were observed for pTNM classification and postal code of birth. During the second audit, a manual of procedures was distributed in the unit, and a new evaluation will be done in one year to assess the impact of guidelines.