[Consistency and validity of the evaluation of the clinical chart].
OBJECTIVE
Assess the degree of external consistency and validity of the EXP CLIN instrument has for measuring the quality information contained in medical charts.


METHODS
In a transverse comparative study, two hundred and twelve clinical charts were randomly selected belonging to patients seen at a pediatric hospital. The charts were assessed using the EXP-CLIN for phases: 1) internal assessment: by hospital personnel of the pediatric hospital, and, II) external assessment: by personnel from other hospitals. The results were analyzed using the concordance method.


RESULTS
The concordance percentages were found to be 76% for medical charts and medical notes related with the process of diagnosis-treatment, as well as the general characteristics of the clinical chart. The concordance percentages average was 88%, supporting the idea that when the EXP-CLIN instrument is applied twice to the same chart, good concordance is obtained between the two measures.


CONCLUSIONS
Given that the application of the instrument documented a good level of external consistency, its use is justified for assessing the quality of the information contained in the charts of the patients seen at our unit.
Navarrete-Navarro
S
S
Unidad de Epidemiología Hospitalaria, C.M.N., SXXI, IMSS.
López-García
G A
GA
Hernández-Sierra
J F
JF
Mejía-Arangure
J M
JM
Rubio-Rodríguez
S
S
D003430:Cross-Sectional Studies; D003625:Data Collection; D006801:Humans; D008499:Medical Records / Q000592:standards* / Q000706:statistics & numerical data; D015588:Observer Variation; D015203:Reproducibility of Results