Evaluación crítica de las historias clínicas de internación de medicina interna Hospital de Clínicas “José de san Martín”
The present research work is focused on analyzing and determining the critical evaluation of the quality of the information in medical records, with an archival perspective. Health documents fulfill the triple social function; source for the history, memory of the institution and guarantee the exerc...
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| Autores principales: | , , , , |
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| Formato: | Artículo revista |
| Lenguaje: | Español |
| Publicado: |
Facultad de Filosofía y Humanidades. Escuela de Archivología
2023
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| Acceso en línea: | https://revistas.unc.edu.ar/index.php/anuario/article/view/43384 |
| Aporte de: |
| Sumario: | The present research work is focused on analyzing and determining the critical evaluation of the quality of the information in medical records, with an archival perspective. Health documents fulfill the triple social function; source for the history, memory of the institution and guarantee the exercise of rights.
A descriptive study was developed to diagnose the level of quality and degree of completion of hospitalization medical records on internal medicine services. The total population is 1633 medical records, therefore the sample is 312. The variables to be observed were the document types “Main Sheet”, “Informed Consent for Admission”, “Epicrisis” and “Clinical Evolution”, determining the absence or complete/incomplete presence of document.
The “Epicrisis” has a high degree of completion, however, there is an absence in the “Main Sheet” and the “Informed Consent”. The “Clinical Evolution” shows that, although the documentation is present, the quality of the information is regular, since the “present” value does not mean that is complete.
The quality of the medical history seems to be compromised, and could impact the performance of the different areas of the Hospital. It is recommended that healthcare and technical-administrative areas work together to ensure compliance with the standards established for the correct completion and adequate management of medical history. |
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