<?xml version="1.0" encoding="ISO-8859-1"?><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<front>
<journal-meta>
<journal-id>1688-1249</journal-id>
<journal-title><![CDATA[Archivos de Pediatría del Uruguay]]></journal-title>
<abbrev-journal-title><![CDATA[Arch. Pediatr. Urug.]]></abbrev-journal-title>
<issn>1688-1249</issn>
<publisher>
<publisher-name><![CDATA[Sociedad Uruguaya de Pediatría]]></publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id>S1688-12492018000500242</article-id>
<article-id pub-id-type="doi">10.31134/ap.89.4.3</article-id>
<title-group>
<article-title xml:lang="es"><![CDATA[Auditoría de historias clínicas: una herramienta de evaluación de la calidad asistencial. Hospital Pediátrico - Centro Hospitalario Pereira Rossell]]></article-title>
<article-title xml:lang="en"><![CDATA[Auditing medical records: a tool to evaluate the quality of medical care. Pediatric Hospital - Pereira Rossell Hospital]]></article-title>
<article-title xml:lang="pt"><![CDATA[Auditoria do prontuário médico do paciente: uma ferramenta de avaliação da qualidade assistêncial. Hospital Pediátrico Pereira Rossell]]></article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Casuriaga]]></surname>
<given-names><![CDATA[Ana]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Giachetto]]></surname>
<given-names><![CDATA[Gustavo]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Gutiérrez]]></surname>
<given-names><![CDATA[Stella]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Martínez]]></surname>
<given-names><![CDATA[Victoria]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[García]]></surname>
<given-names><![CDATA[Ana]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Martínez]]></surname>
<given-names><![CDATA[Fernanda]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Olivera]]></surname>
<given-names><![CDATA[Nancy De]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Boulay]]></surname>
<given-names><![CDATA[Marie]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
</contrib-group>
<aff id="Af1">
<institution><![CDATA[,UDELAR Facultad Medicina Clínica Pediátrica]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Uruguay</country>
</aff>
<aff id="Af2">
<institution><![CDATA[,UDELAR Facultad Medicina Clínica Pediátrica]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Uruguay</country>
</aff>
<aff id="Af3">
<institution><![CDATA[,UDELAR Facultad Medicina Clínica Pediátrica]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Uruguay</country>
</aff>
<aff id="Af4">
<institution><![CDATA[,CHPR Pediatría ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
</aff>
<aff id="Af5">
<institution><![CDATA[,UDELAR Facultad Medicina Clínica Pediátrica]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
<country>Uruguay</country>
</aff>
<aff id="Af6">
<institution><![CDATA[,CHPR  ]]></institution>
<addr-line><![CDATA[ ]]></addr-line>
</aff>
<pub-date pub-type="pub">
<day>00</day>
<month>08</month>
<year>2018</year>
</pub-date>
<pub-date pub-type="epub">
<day>00</day>
<month>08</month>
<year>2018</year>
</pub-date>
<volume>89</volume>
<numero>4</numero>
<fpage>242</fpage>
<lpage>250</lpage>
<copyright-statement/>
<copyright-year/>
<self-uri xlink:href="http://www.scielo.edu.uy/scielo.php?script=sci_arttext&amp;pid=S1688-12492018000500242&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://www.scielo.edu.uy/scielo.php?script=sci_abstract&amp;pid=S1688-12492018000500242&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://www.scielo.edu.uy/scielo.php?script=sci_pdf&amp;pid=S1688-12492018000500242&amp;lng=en&amp;nrm=iso"></self-uri><abstract abstract-type="short" xml:lang="es"><p><![CDATA[Resumen:  Introducción:  la auditoría médica es el análisis crítico y sistemático del proceso de atención que incluye los procedimientos diagnósticos y terapéuticos, el uso de los recursos y los resultados de los mismos. Disponer de un sistema de auditoría constituye un instrumento de mejora continua de la calidad asistencial. Objetivo: evaluar la calidad de las historias clínicas (HC) de los niños hospitalizados.  Material y método:  estudio de corte transversal mediante revisión de HC de niños egresados de áreas de cuidados moderados de un centro de referencia entre el 1º de enero y el 31 de diciembre de 2015. Variables analizadas: datos patronímicos, cuadrícula, curvas de crecimiento, antecedentes socioeconómicos, ingresos, evolución, prescripción, transcripción, diagnóstico al egreso, resumen de egreso. Se establecieron tres categorías: suficiente puntaje mayor o igual a 80%, aceptable 60%-79%, insuficiente &lt;60%. Se analizó la calidad de las HC en función de la edad, estadía hospitalaria, diagnóstico al egreso y estación del año. Se realizó un muestreo aleatorio (prevalencia esperada de error 50%, precisión 5%, poder 80%) (N=385 HC). Se consideró significativa p &lt;0,05.  Resultados:  de las 385 HC analizadas, 52% (202) correspondieron a varones, mediana de edad: 3 meses. Fueron suficientes 17%, aceptables 49,6% e insuficientes 33,4%. Las HC suficientes predominaron en menores de 1 año (21,5% vs 14%) y con estadía menor o igual de 3 días (21% vs 11%) p &lt;0,05. Las HC insuficientes predominaron en invierno (43% vs 29%, p &lt;0,05).  Conclusión:  es necesario profundizar en el estudio de estos resultados mediante un análisis cualitativo. Resulta necesario implementar un sistema de auditoría de HC continuo y avanzar en el desarrollo de los registros electrónicos para mejorar la gestión clínica.]]></p></abstract>
<abstract abstract-type="short" xml:lang="en"><p><![CDATA[Summary:  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&#8217; 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 &lt; 60%. HMR&#8217;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 &lt; 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&lt;0.05. Insufficient HMRs were predominant in Winter (43% vs 29%. p&lt;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.]]></p></abstract>
<abstract abstract-type="short" xml:lang="pt"><p><![CDATA[Resumo:  Introdução:  a auditoria médica é a análise crítica e sistemática do processo de cuidado da saúde, e inclui procedimentos diagnósticos e terapêuticos, o uso de recursos e seus resultados. Ter um sistema de auditoria é um instrumento para melhoria contínua da qualidade do cuidado da saúde.  Objetivo:  avaliar a qualidade dos prontuários eletrônicos das crianças hospitalizadas.  Métodos:  estudo transversal do Prontuário Eletrônico do Paciente (PEP) de pacientes descarregados das áreas de cuidado moderado dum centro de referência entre 1 de janeiro e 31 de dezembro de 2015. As variáveis analisadas foram: dados pessoais dos pacientes, curvas de crescimento, antecedentes socioeconômicos, renda, evolução, prescrição, transcrição, diagnóstico e resumo no momento da alta hospitalar. Três categorias foram estabelecidas: Escore Suficiente maior ou igual 80%, Aceitável 60-79%, Insuficiente &lt;60%. A qualidade do PEP foi analisada em quanto à idade, permanência hospitalar, diagnóstico na alta e estação do ano. Foi realizada uma amostragem aleatória (prevalência esperada de erro de 50%, precisão de 5%, poder de 80%) (N = 385 PEP). Considerou-se significativo p &lt;0,05.  Resultados:  dos 385 PEP analisados, 52% (202) foram do sexo masculino, e a mediana da idade 3 meses. Suficientes 17%, Aceitáveis 49,6% e Insuficientes 33,4%. Os PEP foram suficientes maiormente nas crianças menores de 1 ano (21,5% vs. 14%) e que tinham permanecido menor ou igual 3 dias no hospital (21% vs. 11%) p &lt;0,05. Os PEP foram Insuficientes maiormente no inverno (43% vs. 29%, p &lt;0,05).  Conclusão:  é necessário aprofundar o estudo desses resultados através de uma análise qualitativa. Se deve implementar um sistema contínuo de auditoria de PEP e avançar no desenvolvimento dos Prontuários Eletrônicos para melhorar o gerenciamento clínico dos hospitais.]]></p></abstract>
<kwd-group>
<kwd lng="es"><![CDATA[Auditoría médica]]></kwd>
<kwd lng="es"><![CDATA[Auditoría clínica]]></kwd>
<kwd lng="es"><![CDATA[Calidad de la atención de salud]]></kwd>
<kwd lng="es"><![CDATA[Registros médicos]]></kwd>
<kwd lng="en"><![CDATA[Medical audit]]></kwd>
<kwd lng="en"><![CDATA[Clinical audit]]></kwd>
<kwd lng="en"><![CDATA[Quality of health care]]></kwd>
<kwd lng="en"><![CDATA[Medical records]]></kwd>
<kwd lng="pt"><![CDATA[Auditoria Médica]]></kwd>
<kwd lng="pt"><![CDATA[Auditoria clínica]]></kwd>
<kwd lng="pt"><![CDATA[Qualidade da assistência à saúde]]></kwd>
<kwd lng="pt"><![CDATA[Registros médicos]]></kwd>
</kwd-group>
</article-meta>
</front><back>
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