[Integrated clinical record: unique document for diverse uses]

Abstract

Technological and scientific development and changes in the health system have led to modifications and greater complexity in health documents and clinical records, without there being at the same time definition of guidelines on their correct compilation and formulation. The present study was designed to develop a single Integrated Clinical Record that combines, on the one hand, data of all medical, nursing and technical interventions and, on the other, involves the patient in all decisional processes of diagnosis and treatment during the hospitalization period. All phases of the project related to development of the Integrated Clinical Record are discussed. The data of 240 new clinical records regarding patients admitted consecutively over a period of 6 months are reported. The results show a progressive reduction of compilation errors and an improved management of the patient's clinical course. The innovative aspects of the new clinical record are discussed, with particular reference to the system of quality management, within which context the clinical record has to function, and to the modalities of check, audit and improvement.