García VME, Montero GTJ, Sáez ZG, Pérez SJ

Language: Spanish
References: 15
Page: 2006-2023
PDF size: 183.79 Kb.

ABSTRACT

Introduction: Nowadays, the trend is to measure the medical work quality from the assessment of postmortem diagnoses or of the implementation of clinical method many times in specific pathologies and not in total of clinical entities. One of the indicators of quality in the care area to severe patient is the analysis of deceased, thus, the assessment of medical records may becomes in quality evidence. A form was designed to integrate the tools until now applied to measure the diagnostic coincidences and a general assessment of deceased.
Objectives: To validate the effectiveness of integral form for the assessment of clinical records from deceased patients as an appropriate method for its systematic assessment.
Method: In above mentioned form were included all the pathologic deceased aged over 15 in the area of care to severe patient from January, 2007 to June, 2008. For the creation of the database the descriptive method was used, designing frequency distribution tables and the central trend measures including: the median, the mean, the mode and the interpretation of results obtained with Chi² test, the factorial analysis, the correlation and the linear regression.
Results: From a total of 624 medical records, 423 (67.7 %) were assessed without problem, in 199 (31.8 %) signaling were made and only 2 (0.3 %) had problems.
Conclusions: With the integral form it is possible to contribute to rescue and fomentation of elemental principles of clinical method and the possibility to assess the design process of medical record in a 100 % as well as the appropriate implementation of clinical method and with the confirmation obtained it was possible to contribute to health and disease process.

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