Characteristics of registration of medical records in a hospital in southern Peru
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 Novembe...
| Main Authors: | , , , , |
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| Format: | Article |
| Language: | Spanish |
| Published: |
Universidad de San Martín de Porres
2016-04-01
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| Series: | Horizonte Médico |
| Subjects: | |
| Online Access: | http://www.medicina.usmp.edu.pe/medicina/horizonte/2016_4/Art7_Vol16_N4.pdf |
| Summary: | 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. |
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| ISSN: | 1727-558X 2227-3530 |