Abstract

DELGADO SANCHEZ, María José et al. Filling in the hospital discharge report in an oral and maxillofacial surgery clinical management unit: how to improve it. Rev Esp Cirug Oral y Maxilofac [online]. 2012, vol.34, n.3, pp.111-117. ISSN 2173-9161.  https://dx.doi.org/10.1016/j.maxilo.2011.10.002.

Objectives: To determine the quality and compliance to the information contained in the hospital discharge registry (HDR) issued by the Department of Oral and Maxillofacial Surgery in our hospital. Materials and Methods: A cross-sectional descriptive study was conducted to evaluate 152 HDR reports. These reports included a total of 35 items. We observed that there was a lack of information and some mistakes when filling the HDR boxes. Suitability criteria were set up by consensus as the completion of 90% of the items examined. To evaluate the reliability of the results, an assessment was performed by two reviewers independently, and in case of disagreement the decision was made by consensus after reviewing the medical record. Results: Only 53.94% of the HDR had 90% of the items completed appropriately; 10.74% had some items missing when filling in the form, and 65.79% lacked some information. Depending on the type of item there was a significant variation in the completion of the form. Conclusions: In the present work, we assess the quality of a specific hospital discharge form in our hospital, with items previously selected as useful and appropriate to reflect a complete, accurate and precise view of the care process of the patient, and improvements were needed in items such as, telephone, home address, date of consultation, biopsy report and the date it was performed, ambulatory surgery and emergency response.

Keywords : Hospital discharge records; Medical audits; Process evaluation; Quality of the care; Surgery.

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