title: [Importance of the quality of the discharge report in the management of a surgical clinical unit].
abstract: BACKGROUND
  The discharge report is a basic document at the end of a care process, and is a key element in the coding process, since its correct wording, reliability and completeness are factors used to determine the hospital production.
  
  
  METHODS
  From a hypothesis based on the analysis of the consistency between the discharge report and data collected from the routine clinical notes during admission, we should be able to re-code all those mis-coded, thus placing them in a more appropriate diagnosis-related group (DRG). A total of 24 patient outliers were analysed for the correct filling in of the type and reason for admission, personal history, medication, anamnesis, primary and secondary diagnosis, sugical procedure, outcome, number of diagnostic and procedures cited, concordance between discharge report and history and recoding of the DRG.
  
  
  RESULTS
  From a total of 24 episodes, 6 had precise and valid reports, 4 were valid but not precise enough, 9 were insufficient, and 5 were clearly invalid. The recoded DRG after the documentation review was not significantly different, according to the Wilcoxon test, being changed in only 5 cases (P = .680).
  
  
  CONCLUSIONS
  Quality in discharge reports depends on an adequate minimum data set (MDS) in concordance with the source documentation during admission. Discordance can change the DRG, despite it not being significantly different in our series. Self-audit of discharge reports allows quality improvements to be developed along with a reduction in information mistakes.
authors: Unidad Clínica de Gestión Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen Macarena, Sevilla, España. dr.gomez.rosado@gmail.com
authors: Juan-Carlos
authors: JC
authors: Gomez-Rosado
authors: María
authors: M
authors: Sanchez-Ramirez
authors: Javier
authors: J
authors: Valdes-Hernandez
authors: Luis C
authors: LC
authors: Capitan-Morales
authors: Marta I
authors: MI
authors: Del-Nozal-Nalda
authors: Fernando
authors: F
authors: Oliva-Mompean
mesh_terms: D003953:Diagnosis-Related Groups; D006757:Hospital Units / Q000458:organization & administration*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D010351:Patient Discharge; D011786:Quality Control; D013503:Surgery Department, Hospital / Q000458:organization & administration*; D013514:Surgical Procedures, Operative