[Hospital clinical records accuracy in traceability of healthcare associated infections]

We conducted a retrospective analysis on health care records in order to validate its accuracy in the reporting of healthcare associated infections (HAIs) for the purpose of supporting epidemiological surveillance and nursing-sensitive patient outcomes studies. The health care records have been selected on the basis of the database of alert microorganisms in a teaching Hospital of North-Eastern of Italy, for the years 2005-2006-2007 in three wards (Hematology, ICU and Surgical ward). In 80/107 (74.8%) cases of alert microorganisms a written record was found in the patient's health care records, most frequently in the nursing records (64/80, 80%). In the health care records have been reported 21 diagnosis of infection (21/107, 19.6%). The presence of written symptoms was heterogeneous among the different sources considered (medical and nursing records, vital parameters and therapy sheets). The results are not completely satisfactory from the point of view of the information accuracy. The promotion of integrated clinical health care record systems (doctors/nurses), also electronics, a more accurate compilation and periodical supervision would be needed.