Abstract

FERNANDEZ-VALENCIA, Jenaro A. et al. Quality of hospital discharge report conducted by surgical resident physicians. FEM (Ed. impresa) [online]. 2015, vol.18, n.3, pp.205-210. ISSN 2014-9840.  https://dx.doi.org/10.4321/S2014-98322015000400009.

Introduction: Resident intern physicians (MIR) must become competent in writing correct hospital discharge reports (HDR). This document must contain a minimum data set, and should be understandable to the patient, family doctor or other professionals. The acquisition of this competence has been little studied, and the quality of HDRs performed by MIR has not been previously evaluated. Subjects and methods: The present study evaluated the quality of 124 emergency HDRs comparing those signed by specialists, only signed or signed by MIR, or signed by MIR and specialist in the fields of Orthopaedic Surgery and General Surgery. Results: The result has been more favourable than that of previous publications, with a score of 7 out of 10 in 94.4 % of cases. HDRs made by first-year residents and supervised by specialists obtained the best scores with statistically significant differences (p = 0.003). No differences were observed between the reports by the morning or night (p = 0.6). In terms of content, 12.9 % of reports had acronyms difficult to understand. Conclusion: Our study depicts the beneficial effect of HDR monitoring in the first year of residency as well as an improvement objective by minimizing the use of medical abbreviations.

Keywords : Hospital discharge report; MIR; Postgraduate medical education.

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