RESUMO
El eje de la auditoria médica es una historia clínica adecuadamente confeccionada. La historia clínica es la constancia escrita detodos los exámenes médicos, estudios realizados y tratamientos aplicados durante el transcurso de la enfermedad.Objetivo:Evaluarla calidad de registro de las historias clínicas de Consultorios Externos del Servicio de Medicina Interna en la Clínica CentenarioPeruano Japonesa.Diseño:Descriptivo de corte transversal.Lugar: Consultorios externos del Servicio de Medicina Interna de laClínica Centenario Peruano Japonesa.Material:Historias clínicas de pacientes atendidos en la consulta externa del Servicio deMedicina Interna.Métodos:Se evaluó 323 historias clínicas mediante un muestreo aleatorio simple, las cuales fueron sometidasa una ficha de auditoría que comprendía 10 ítems, cada uno calificado con 10 puntos, para un total de 100 puntos: fecha y horade atención, pulcritud y legibilidad, anamnesis adecuada, signos vitales, examen físico, diagnóstico, plan de trabajo, exámenesauxiliares, tratamiento completo...
Core of medical audit is a properly tailored medical history. The medical record includes all medical examinations, studies conducted and treatments applied during the course of the disease. Objectives: To assess medical records registration quality of Internal Medicine doctors offices at Clinica Centenario Peruano Japonesa. Design: Descriptive cross-sectional study. Location: Internal Medicine outpatient offices at Clinica Centenario Peruano Japonesa. Material: Clinical records of patients attended in Internal Medicine doctors offices. Methods: Three hundred and twenty-three medical records were collected by random sampling and subjected to a 10-items record audit, each rated at 10 points, for a total of 100 points. Items included date and time of care, neatness and legibility suitable record, vital signs, physical examination, diagnosis, plan of work, laboratory findings, complete treatment, and signature and stamp of the physician. Records with total score more than or equal to 80 were rated as acceptable, and all others as need to improve. Main outcome measures: Acceptable or need to improve medical records. Results: Two hundred and six (63.8 per cent) clinical records were rated as acceptable and 117 (36.2 per cent) as need to improve. Items diagnosis and complete treatment presented poor registry more frequently, both in records with acceptable registry (filled in completely in 64.6 per cent and 62.6 per cent respectively) and those with need to improve registry (20.5 per cent and 23.1 per cent respectively). Signature and seal of the attending physician were the best items in both categories (99.5 per cent and 93.2 per cent respectively). Conclusions: More than half of the medical records had an acceptable quality at the Clinica Centenario Peruano Japonesa.
Assuntos
Assistência Ambulatorial , Auditoria Médica , Controle de Formulários e Registros , Prontuários Médicos , Estudos Retrospectivos , Estudos TransversaisRESUMO
INTRODUCCIÓN: Las infecciones intrahospitalarias constituyen un indicador de calidad de atención de los Establecimientos de Salud, aspecto que permite determinar la capacidad técnica del personal de salud y su equipamiento. OBJETIVO: Determinar el perfil epidemiológico de los pacientes con infecciones intrahospitalarias durante el año 2011. MATERIAL Y MÉTODOS: Se realizó un estudio prospectivo, observacional de corte longitudinal a pacientes hospitalizados en la Clínica durante el año 2011. RESULTADOS: Se evaluó 2379 pacientes hospitalizados, con 4,19±0,28 días de hospitalización. Encontrándose a 41 pacientes con Infecciones intrahospitalarias, representando una prevalencia del 1,72%. En el perfil epidemiológico predominó en el sexo femenino, con edades de 68,9±22.72 años, estancia hospitalaria de 14,98±9,6 días, siendo 3,57 veces más alta al promedio de hospitalización en la clínica. La Infección más prevalente fue la Neumonía Intrahospitalaria (60.98%), siendo la tasa asociada a ventilador mecánico de 13,56 por 1000 días de exposición. Las infecciones asociadas a catéter urinario y catéter venoso central son 6.34 y 3.24 por cada 1000 días de exposición respectivamente. La tasa de mortalidad correspondió a 34.15%. CONCLUSIONES: Los pacientes que sufrieron Infección intrahospitalaria; son de características longevas, con antecedentes de enfermedades crónicas, que condicionan una estancia prolongada y teniendo como principales Infecciones intrahospitalarias a la neumonías e infecciones urinarias.
OBJETIVE: To determine the epidemiological profile of patients with hospital-acquired infections in 2011.MATERIAL AND METHODS: We performed a prospective, observational, longitudinal study to inpatients at the Clinic in 2011. RESULTS: We evaluated 2379 patients hospitalized with 4.19 ± 0.28 days in hospital. Found 41 patients with nosocomial infections, representing a prevalence of 1.72%. The epidemiological profile: most were females, aged 68.9 ± 22.72 years, with a hospital stay of 14.98 ± 9.6 days, being 3.57 times higher than average hospital stay. Nosocomial pneumonia was the most prevalent Infection (60.98%), while the rate associated with mechanical ventilator is 13.56 per 1000 days of exposure. The infections related to urinary catheter- and central venous catheter are 6.34 and 3.24 per 1000 days of exposure, respectively. The mortality rate was to 34.15%.CONCLUSIONS: Patients who had nosocomial infections, are elderly patients, with a history of chronic diseases, which condition an extended stay and have as principal nosocomial infections pneumonia and urinary tract infections.
Assuntos
Humanos , Masculino , Feminino , Idoso , Qualidade da Assistência à Saúde , Infecção Hospitalar , Instalações de Saúde , Perfil de Saúde , Estudos Longitudinais , Estudos Prospectivos , Estudos Observacionais como AssuntoRESUMO
The mechanochemical transformation of Ca(OH)(2)-(NH(4))(2)HPO(4) with different Ca/P ratios 1; 1.5; 1.67 and 1.75 was carried out for different periods of time from 10 min to 24 h in a horizontal vibration mill using steel and agate vials and balls. The phase transformations obtained at each milling stage were characterized by X-ray diffraction, infrared spectroscopy and transmission electron microscopy. Complete transformation to hydroxyapatite took place during the first 5 h of milling, for Ca/P ratios 1.5 to 1.7, when milling was carried out with steel vials and balls. The contamination was not significant for the periods of milling studied for both milling media.