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Assessment of the maintenance of the SMUR medical records: Internal audit

Assessment of the maintenance of the SMUR medical records: Internal audit

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Medical Reference

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ISBN10: 6630449967
ISBN13: 9786630449969
Publisher: Our Knowledge Publishing
Pages: 68
Weight: 0.23
Height: 0.16 Width: 6.00 Depth: 9.00
Language: English
The aim of this study was to assess the quality of the maintenance and completion of SMUR medical records in order to identify shortcomings and propose corrective measures. A clinical audit was carried out at the Sahloulau SMUR (SAMU 03). Records of primary, primary-secondary and secondary call-outs occurring during the day, at night and at weekends throughout 2015 were analysed using a data collection form comprising 62 criteria based on the SMUR reference framework and the 2013 assessment guide published by the French Society of Emergency Medicine and Samu-urgences de France. A total of 922 records were analysed. The highest non-compliance rate (55.2 per cent) was found in the section 'specifics of the SMUR record'. The lowest non-compliance rate was found in the 'monitoring data' section (15.1 per cent). This audit identified minor shortcomings. These may be due to the absence of Tunisian guidelines on the maintenance of patient records in general and SMUR records more specifically. Corrective measures have been implemented as part of a short- and medium-term action plan.

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