Evaluacion de la calidad de registro de historias clinicas en consultorios externos del servicio de medicina interna de la Clinica Centenario Peruano Japonesa, 2010-2011 / Quality assessment of medical records at Clinica Centenario Peruano Japonesa internal medicine doctor’s offices, 2010 – 2011

RESUMEN

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...

ABSTRACT

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 doctor’s 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 doctor’s 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.