Abstract

FLORES SERNA, Antonio F. Quality of clinical records prepared by the medical interns - UMSA La Paz 2017. Cuad. - Hosp. Clín. [online]. 2018, vol.59, n.1, pp.19-28. ISSN 1562-6776.

INTRODUCTION: The medical intern activity, considers as a pre-professional practice, developed in a "real" context, meaning that the interns carry out their training with real patients. The elaboration of the Clinical Record (H.Cl.) should therefore contain the best patient information. OBJECTIVE: aimed at identifying the quality of the elaboration of H. Cl. by the medical interns of UMSA. MATERIAL AND METHOD: The design corresponds to a quantitative, observational, longitudinal and analytical investigation. Methodologically, 8 interns were monitored during 2015, reviewing the H.Cl. that they elaborated during their different internships in the specialties of Medicine, Pediatrics, Surgery, Gynecology - Obstetrics, constituting a total of 64 clinical files, 8 per intern. For the evaluation of the quality of the H.Cl. A template with five topics was used, whose validation was detached from the procedure used in the internal auditing used in the hospitals. RESULTSAND DISCUSSION: Only 19 H.Cl. achieved the category ofacceptable (29.7%), compared to the other two categories 15 H.Cl. were classified as insufficient (23.4%) the rest of the clinical histories 30, suffered from several defects that were classifiedas unacceptable (46.9%). It can be noted that only three out of ten H.Cl. were elaborated appropriately, additionally close to half of the total of the documents were pointed out as unacceptable, reflecting the H.Cl. were improperly elaborated, cataloged as ofpoor quality CONCLUSIONS: The evaluation on the quality of H. Cl. allowed identifying and highlighting the presence of a marked gap between the ideal purpose sought by the major curriculum and the final product as part of the professionalization process.

Keywords : Writing of clinical records; quality of clinical record; performance.

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