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Introduction:Effective management of medical records is essential for delivering high‑quality treatment. The location, architecture, and personnel of a medical records department (MRD) can considerably impact its operational efficiency. This study seeks to examine hospital MRD and establishes whether its current configuration is suitable for effective medical record management. Materials and Methods: The descriptive method was utilized to evaluate the MRD of the hospital. The review analyzed the department’s physical layout, personnel, workload, training programs, and available equipment. The study also evaluated the influence of government and business restrictions on MRDs operations. Results: It was determined that the MRD of the hospital had an appropriate physical layout, with divisions positioned in optimal locations. The department’s personnel levels were adequate, with twenty employees managing the patient population’s workload. The analysis determined that the department required extra photocopiers and scanners to boost operational efficiency. In addition, the study underlined the significance of adhering to policies, protocols, and established processes in ensuring efficient workflow. Conclusion: The analysis concludes that the hospital MRD has an adequate physical layout, staffing levels, and task management. However, the present equipment could be enhanced to increase operational efficiency. The study also emphasizes the importance of adhering to policies, protocols, and written processes to ensure the department’s efficient workflow. The outcomes of this study may inform future decisions on MRD management in other health‑care organizations, especially those subject to comparable government and commercial regulations
ABSTRACT
Introducción: La depresión es un trastorno del ánimo frecuente, cuya recurrencia altera su manejo y pronóstico. El objetivo del trabajo es describir la tasa de egreso hospitalario (TEH) por episodio depresivo recurrente (EDR) entre 2018-2021 en Chile, según sexo, edad y gravedad. Materiales y métodos: Estudio observacional y transversal que considera los egresos hospitalarios por EDR en el período 2018-2021 en Chile (N=1551). Se utilizaron las bases de datos del Departamento de Estadísticas e Información de Salud y el Instituto Nacional de Estadística. Las variables estudiadas fueron sexo, grupo etario y gravedad. No requirió aprobación de comité de ética. Resultados: Se observó la menor TEH en 2020 con 1,91 egresos por cada 100.000 habitantes. Las mujeres sobresalieron durante todo el período con una TEH de 3,68 egresos por cada 100.000 habitantes. Destacó el grupo de 15 a 19 años con la mayor TEH en ambos sexos con 5,3 egresos por cada 100.000 habitantes. Respecto a gravedad, las hospitalizaciones se concentraron en pacientes de diagnóstico no especificado. Discusión: La pandemia de COVID 19 podría explicar la disminución de la TEH en 2020, al reducirse el diagnóstico y hospitalización por EDR; presumiblemente debido al fenómeno de reconversión de camas. La TEH es mayor en el sexo femenino, lo cual es concordante con la literatura. El predominio del grupo de 15 a 19 años discrepa de la evidencia, la cual indica que suele concentrarse en individuos de 25 a 64 años. Conclusión: Las TEH por EDR se concentraron en mujeres jóvenes. Es relevante conocer la epidemiología local para focalizar los recursos en la detección oportuna de factores de riesgo, para evitar episodios graves y disminuir su recurrencia.
Introduction: Depression is a common mood disorder, whose recurrence alters its management and prognosis. The aim of the paper is to describe the hospital discharge rate (HED) for recurrent depressive episode (RDE) between 2018-2021 in Chile, according to sex, age and severity. Materials and methods: Observational and cross-sectional study considering hospital discharges due to DRE in the period 2018-2021 in Chile (N=1551). The databases of the Department of Health Statistics and Information and the National Institute of Statistics were used. The variables studied were sex, age group and severity. Ethics committee approval was not required. Results: The lowest HTE was observed in 2020 with 1.91 discharges per 100,000 inhabitants. Females stood out during the entire period with an HTE of 3.68 discharges per 100,000 population. The 15-19 years age group stood out with the highest HTE in both sexes with 5.3 admissions per 100,000 inhabitants. In terms of severity, hospitalizations were concentrated in patients with unspecified diagnosis. Discussion: The COVID 19 pandemic could explain the decrease in HTE in 2020, with a reduction in diagnosis and hospitalization for RDE, presumably due to the bed conversion phenomenon. HTE is higher in the female sex, which is consistent with the literature. The predominance of the 15 to 19 years age group disagrees with the evidence, which indicates that it tends to be concentrated in individuals aged 25 to 64 years. Conclusion: HTE due to DRE was concentrated in young women. It is important to know the local epidemiology in order to focus resources on the timely detection of risk factors to avoid serious episodes and reduce their recurrence.
Subject(s)
Humans , Male , Female , Child , Adolescent , Adult , Middle Aged , Aged , Aged, 80 and over , Young Adult , Depressive Disorder/epidemiology , Psychiatric Department, Hospital , Epidemiology, Descriptive , Hospitalization/statistics & numerical data , Medical Records Department, HospitalABSTRACT
Objetivo: conocer la proporción de diagnósticos codificados adecuadamente de acuerdo a la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud, Décima Revisión, a consecuencia del registro correcto por parte del médico tratante en los reportes diarios de consulta externa, en un hospital de segundo nivel de Cárdenas, Tabasco, México, en el año 2009. Materiales y Métodos: se realizó una investigación transversal en sistemas de salud, en la cual, de 450 formatos de registro de consulta externa (N = 450) generados durante los meses de abril a octubre de 2009 en un hospital general de seguridad social de Tabasco, México, se tomó una muestra probabilística de 39 formatos (p = 0,8, Z = 1,645, d = 0,1), de la que se excluyeron dos rotos y uno manchado, siendo estudiados 36 (n = 36) que incluían 372 diagnósticos registrados, a los que se revisó calidad del registro y concordancia con los nombres de padecimientos según la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud, Décima Revisión, y se describió su impacto sobre la calidad de la codificación de parte del departamento de estadística. Resultados: de 372 registros estudiados, el 50% mostraron error, siendo el más común el uso de abreviaturas o siglas (37,4%). Solo 100 (26,9%) de los registros incluidos presentaron concordancia con la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud, Décima Revisión, observándose que en 131 de los casos (35,2%) se logró una codificación exitosa. Conclusiones: el 65% de la morbilidad reportada por el departamento de estadística no corresponde a la realidad, lo que lleva a la toma de decisiones administrativas con información de baja calidad.
Objective: To know the proportion of properly coded diagnosis according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, as a result of successful registration by the treating physician in outpatient daily reports in a second level hospital from Cardenas, Tabasco, Mexico, in 2009. Materials and Methods: A cross sectional research was conducted in health systems, in which, from 450 outpatient registration forms (N = 450) generated during April to October 2009 in a general hospital of social security from Tabasco, Mexico, it was taken a probability sample of 39 forms (p = 0.8, Z = 1.645, d = 0.1), from which were excluded two broken and one dirty, being studied 36 forms (n = 36) which included 372 diagnoses registered, whose register quality and consistency with the names of diseases according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, were reviewed, and it was described their impact on the quality of the coding, on behalf the Statistic Department. Results: From 372 studied records, 50% showed mistake, being the most common the use of abbreviations or acronyms (37.4%). Only 100 (26.9%) of the records included presented consistency according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, observing that in 131 cases (35.2%) a successful coding was achieved. Conclusions: 65% of morbidity reported by the Statistical Department does not correspond to reality, leading to management decisions with poor quality information.