[Quality of discharge reports prepared by the services of internal medicine in Castilla-La Mancha (assessment of clinical data)].
We analyzed several aspects of the quality (at the level of clinical data) of discharge reports prepared by the Services of Internal Medicine in the hospitals of Castilla-La Mancha, taking into account that these are the end written products of the health care activity. We analyzed 800 reports and we found terms such as "probably, not discarded" in the clinical judgment in 150 reports out of 794 and abbreviations in 370 out of 792. 10.8% of the reports written at discharge (86 out of 794) were waiting for the results, reflecting thus severe shortcomings in the clinical data of these reports, that must be corrected in our area.
Viana Alonso
A
A
Servicio de Medicina Interna, Estudio Multicéntrico Castilla-La Mancha, Hospital Universitario, Guadalajara.
Portillo Pérez-Olivares
H
H
Rodríguez Rodríguez
A
A
Hernández Lanchas
C
C
Rosa Herranz
C
C
de la Morena Fernández
J
J
D006753:Hospital Records / Q000592:standards*; D006801:Humans; D010351:Patient Discharge / Q000592:standards*; D011786:Quality Control; D013030:Spain
Calidad de los informes de alta de Castilla-La Mancha en los servicios de medicina interna (valoración de la información clínica).