SciELO - Scientific Electronic Library Online

 
vol.89 issue4Nasopharyngeal colonization from Streptococcus pneumoniae serotypes in Uruguayan children before and after pneumococcal conjugate vaccinesOutpatient skin and soft tissue infections treated in a pediatric hospital in Uruguay after 10 years of MRSA epidemic author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Related links

Share


Archivos de Pediatría del Uruguay

Print version ISSN 0004-0584On-line version ISSN 1688-1249

Abstract

CASURIAGA, Ana et al. Auditing medical records: a tool to evaluate the quality of medical care. Pediatric Hospital - Pereira Rossell Hospital. Arch. Pediatr. Urug. [online]. 2018, vol.89, n.4, pp.242-250. ISSN 0004-0584.  https://doi.org/10.31134/ap.89.4.3.

Introduction:

medical audits involve critical and systematic analysis of the medical care process, diagnostic and therapeutic procedures, the use of resources and the results obtained. Auditing systems provide tools for quality continuous improvement.

Objective:

to assess the quality of medical records (HMR) of hospitalized children.

Material and methods:

HMR cross-sectional study of of children discharged from moderate care units at a reference hospital center between January 1 and December 31, 2015. Analyzed Variables: patients’ personal data, grids, growth curves, socio-economic background, admissions, evolution, prescription, transcription, diagnosis at discharge, discharge Report 3 categories were devised: Sufficient score greater or equal 80%, Acceptable 60-79%, Insufficient < 60%. HMR’s quality was analyzed by age, hospitalization time, diagnosis at discharge and season of the year. Random sampling was carried out (expected error prevalence 50%, accuracy 5%, power 80%) (N=385). P < 0,05 was considered significant.

Results:

Out of 385 HMRs analyzed, 52% (202) were boys, median age 3 months-old. 17% were sufficient, 49.6% were acceptable and 33.4% were insufficient. Sufficient HMRs were predominant in children of less than 1 year-old (21,5% vs 14%) which had a hospitalization time of less or equal 3 days (21% vs 11%) p<0.05. Insufficient HMRs were predominant in Winter (43% vs 29%. p<0.05).

Conclusion:

A qualitative analysis is needed in order to reinforce the analysis of these results. It is important to implement a continuous HMR auditing system in order to make progress regarding the development of electronic records as a tool to improve the clinical management systems.

Keywords : Medical audit; Clinical audit; Quality of health care; Medical records.

        · abstract in Spanish | Portuguese     · text in Spanish     · Spanish ( pdf )