Resumo

LARRIEGA QUISPE, Anhela Leyla  e  COSSIO BOLANOS, Wilbert Juvenal. Quality of the medical records of the dental service of a hospital center, Lima, Peru. Vive Rev. Salud [online]. 2025, vol.8, n.23, pp.586-597.  Epub 01-Maio-2025. ISSN 2664-3243.  https://doi.org/10.33996/revistavive.v8i23.399.

The aim of the following study was to evaluate the quality of the medical records of the dental service of a hospital center in Lima, Peru, based on the criteria established by the current regulations of the Ministry of Health. Materials and Methods: A descriptive, cross-sectional, retrospective and observational non-experimental study design. The sample consisted of 115 medical records obtained by applying a formula for estimating a known population. The instrument used for data collection was the form of the Technical Standard for Auditing the Quality of Health Care provided by the Ministry of Health (MINSA). Results: Of the total number of medical records studied, 56.0% were found to be in the deficient category and 44.0% had a record to be improved, which indicates that only a certain percentage had the capacity to adequately record the medical records as required. There was room for improvement in the following categories: anamnesis 61.0%, diagnosis 88.0%, treatment 63.0% and attributes 83.0%. There were deficient records in the following categories: physical examination 45.0% and ancillary examinations 51.0%. Conclusion: The audit of the quality of the dental service records in September 2019 of the Carlos Lanfranco la Hoz Hospital was found to be between deficient and in need of improvement.

Palavras-chave : Medical Records; Dental Audit; Clinical Records; Dentistry; Dentistry.

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