Resumo

LLANOS-ZAVALAGA, Luis Fernando; MAYCA PEREZ, Julio  e  NAVARRO CHUMBES, Gian Carlos. Medical audit of patient records at an outpatient clinic in four Peruvian public hospitals. Rev Med Hered [online]. 2006, vol.17, n.4, pp.220-226. ISSN 1018-130X.

Medical audit is defined as a critical and systematic assessment of the quality of health care, including procedures, resources used and outputs that influence on the clinical outcome and the patient quality of life. Objectives: This study assesses the filling of medical records (HC) at the outpatient consultation, allowing identifying information gaps or mistakes. Material and Methods: A descriptive cross-sectional study was done. We included representative random samples of new patients of 04 public MINSA hospitals at the northern coast (Lambayeque -390 HC), southern coast (Ica -396 HC), andean area (Junín -384 HC), and amazon basin (Amazonas -396 HC). The sampling and analysis unit was HC of patients at outpatient consultation. Results: We found: register of vital signs in 8.75% of the HC, register of symptoms at consultation in 91.08%, register of physical examination in 56.63%, register of patient diagnoses in 97.43%, register of treatment and/or plan analysis in 89.37%, register of date and hour in 13.70%, and register of professional signature and stamp in 54.65%. We observed significant differences between the hospitals. Conclusions: As reported somewhere else, filling of HC is poor for most of the variables assessed. We expected high values for the aspects considered important by health professionals for a good healthcare. Medical audit will improve the standards of clinical practice as health professionals understand and convinced themselves of its value as an educational tool. (Rev Med Hered 2006;17:220-226).

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

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