Characteristics of registration of medical records in a hospital in southern Peru
| Autor: | Cender Udai Quispe-Juli, Rossi Yessenia Navarro-Navides, Luis Gustavo Velásquez-Chahuares, Frank Pinto-Martínez, Elvis Olivares-Alegría |
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| Jazyk: | Spanish; Castilian |
| Rok vydání: | 2016 |
| Předmět: | |
| Zdroj: | Horizonte Médico, Vol 16, Iss 4, Pp 48-54 (2016) |
| Druh dokumentu: | article |
| ISSN: | 1727-558X 2227-3530 |
| Popis: | Objective: To determine the characteristics of registration of medical records of hospitalization in the Hospital III Yanahuara in Arequipa, Peru. Material and methods: The study was observational, cross-sectional and retrospective. 225 medical records of hospitalization were evaluated in November 2015. A tab consisting of 15 items was used; each item was assessed using a scale: "very bad", "bad", "acceptable", "good" and "very good". Adescriptive analysis was done by calculating frequency. Results: Items with a higher proportion of acceptable registration data were: clear therapeutic indication (84%), clinical evolution (74.7%), diagnosis (70.7%), complete and orderly therapeutic indication (54.2%), medical history taking (50.2%) and physical examination (43.1%). The very well recorded items were: indication of tests and procedures (97.3%), medical identification (91.1%) and allergies (67.1%). Very bad recorded items were: reason for admission (91.1%), life habits (72.9%) and prior treatment (38.2%). Conclusions: Most medical records of hospitalization are characterized by an acceptable record of most evaluated items; however they have notable deficiencies in some items. |
| Databáze: | Directory of Open Access Journals |
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