QI | Number of records in random sample (n)* | Calculation |
---|---|---|
Traceability of pain assessment | 80† | Proportion of records containing at least one pain assessment result (number of records with at least one result/n) |
Quality and content of the medical record | 80† | Composite score (compliance with 10 items): presence of: surgical report, delivery report, anaesthetic record, transfusion record, outpatient prescription, outpatient record, admission documents, care and medical conclusions at admission, and drug prescriptions during stay; overall medical record organisation |
Quality and content of the anaesthetic record | 60 | Composite score (compliance with 13 items). Presence of the following information:
|
Time elapsed before sending discharge letters | 80† | Proportion of records containing a letter sent to the patient's general practitioner within 8 days (number of records containing a letter/n) |
Screening for nutritional disorders | 80† | Proportion of records giving body weight (BW) at admission (number of records with BW/n) |
Management of acute myocardial infarction at hospital discharge‡ (8 QIs) | 60 | Proportion of records 1. With prescription for an antiplatelet drug (number with prescription+number justifying absence of prescription /n) 2. With prescription for a beta-blocker (number with prescription+number justifying absence of prescription /n) 3.1. With left ventricular ejection fraction (LVEF) measurement (number with LVEF/N) 3.2. With LVEF <40% and prescription for an angiotensin-converting enzyme inhibitor (number of records with prescription/number of records with LVEF <40%) 4.1. With prescription for a statin (number with prescription+number justifying absence of prescription/n) 4.2. With prescription for a statin and order for lipid test (number of records with an order/number of records with a prescription) 5. With advice on diet (number of records with advice/n) 6. Of patients with a history of cigarette smoking who received advice on giving up (number of records with advice/number of records for patients with history of cigarette smoking) |
*Previous year records for patients hospitalised for more than 1 day.
†Same sample used to measure 4 QIs.
‡Patients who died in hospital were excluded.
QI, quality indicator.