Resumo

PERATA SALAZAR, Marianella; LLANOS ZAVALAGA, Luis Fernando; CABELLO MORALES, Emilio Andrés  e  MAYCA PEREZ, Julio. Medical audit of outpatient pediatric care of a general hospital in Lima-Perú. . Rev Med Hered [online]. 2006, vol.17, n.1, pp.35-41. ISSN 1018-130X.

The healthcare quality can be measured based on the fill-in of medical record (HC), a medical-legal document that registers the identification of the patient, its health, disease, diagnosis, evolution and therapy. For it the medical audit of secondary sources is made as a study of quality of fill-in. Objective: To evaluate the quality of data registered in HC of outpatient care of new patients attending consultation at General Pediatrics at the Hospital Nacional Cayetano Heredia (HNCH). Material and Methods: A descriptive retrospective cross-sectional study was made, including 384 HC selected by simple random sampling with replacement. We considered the following dimensions: general patient data, anamnesis, physical examination, diagnosis, work plan, treatment and identification of the medical doctor; the variable was measured dichotomously (presence or absence of the variable). Results: The reason for consultation, weight and height of patient were present in all HC. Date, age, and physical examination were present in more of 90%, the name and number of HC in less of 50%, whereas the biological functions and vital functions in less of 20%. The diagnosis was registered in 99.2% and the work plan in 84.6%. Pharmacological treatment was complete in 7.4%. The identification of the doctor was completed only in 49.7%. Conclusions: The quality of the data registered in the HC of new patients of outpatient care General Pediatrics in HNCH is deficient, being necessary to implement mechanisms that allow of effective way to the doctors and multidisciplinary healthcare team to monitor and improve the quality of care which they offer to his patients. (Rev Med Hered 2006;17:35-41).

Palavras-chave : Audit; medical audit; medical record; data quality.

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