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Online ISSN 1827-1677
Genovese U., Macrì L., Casiraghi G.
The authors analysed the juridical and medical-legal effectiveness of the clinical record and of the hospital dismission form, commonly indicated as SDO and established throughout the national territory since 1992 in order to collect health, epidemiological and financial data. The new rules regarding the National Health System fundings have given a particular attention to the information contained in the SDO; it is thus compulsory to collect data on hospitalization in a complete and correct way. Payment is now achieved according to the services accomplished. Therefore SDO must be accurately filled in since it is considered part of the clinical record and thus bears the same medical-legal value. It schematically illustrates the event occurred during hospitalization. Hence they require the need of an organized informatic support with a database which can evaluate the control of quality of a particular hospital. The system should indicate in a short time the information received as indicators of the activity performed.
The authors have also briefly analysed the different problems emerging during activities of the Lombardia Region Control Group (NOC), so as to suggest possible solutions. This is important since these problems have created a major involvement of the Law system.