[The quality of the discharge reports from the internal medicine services of Castilla-La Mancha (a structural evaluation)].
The discharge report is one of the final outputs of the health care activity. We have tried to analyze several aspects related to its quality. For this purpose, we conducted a cross-sectional study analyzing 800 reports of patients admitted in the services of Internal Medicine at 6 hospitals of Castilla-La Mancha during the year 1991. We must stress the absence of discharge reports for death patients and the failure to record drug allergies (69.9%), medical history (10.4%) and time of evolution of the disease (16.9%), as well as treatment in 17 reports out of 781 and follow-up review after discharge in 12.8%.


CONCLUSIONS
Discharge reports have a low scientific content and the production of this type of records is not a routine practice in the case of death patients.
Servicio de Medicina Interna, Estudio Multicéntrico Castilla-La Mancha.
A
A
Viana Alonso
C R
CR
Herranz
H
H
Portillo Pérez-Olivares
A
A
Rodríguez Rodríguez
C
C
Hernández Lanchas
J
J
de la Morena Fernández
D003644:Death Certificates; D005568:Forms and Records Control / Q000592:standards / Q000706:statistics & numerical data; D006753:Hospital Records / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D007388:Internal Medicine / Q000458:organization & administration* / Q000706:statistics & numerical data; D010351:Patient Discharge / Q000592:standards* / Q000706:statistics & numerical data; D013030:Spain
Calidad de los informes de alta de los Servicios de Medicina Interna de Castilla-La Mancha (valoración de la estructura).