Quality of recording the clinical histories of the hospitalization service of the El Bosque Maternal Child Health Center. Trujillo, Perú. 2019.

Abstract

The quality of the registry (QR) of the clinical records (CR) of the hospitalization service of the El Bosque Maternal and Child Health Center in Trujillo (Perú) was evaluated in February 2019 in a retrospective, cross-sectional study in 20 CR of patients attended by vaginal delivery and puerperium. Damaged, incomplete, lost or unlocatable CRs, and those of patients referred to other hospitals for definitive care were excluded. To evaluate QR, the Health Technical Standard for Health Care Quality Audit of the Ministry of Health of Perú was used. A 100% satisfactory quality (SQ) was obtained in the registration of the CRs in the global evaluation. The QR was 100% satisfactory in the dimensions of current disease and history, work plan, treatment and special formats. The dimensions of affiliation, clinical examination, progress notes, nursing / obstetric records, and discharge specifications presented 95% SQ. The diagnostic dimension presented 65% of SQ and the dimension attributes of the CR, obtained 45% of SQ. None of the CRs were of poor quality. It is concluded that the QR of the CR was satisfactory, with some dimensions to improve.