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Revista Estomatológica Herediana
versão impressa ISSN 1019-4355
Resumo
HERNANDEZ ESPINO, Raúl e MERCADO MARRUFO, Celia. Quality of registration of dental medical records in a health center in the city of Ica, Peru. Rev. Estomatol. Herediana [online]. 2023, vol.33, n.3, pp.199-206. Epub 23-Set-2023. ISSN 1019-4355. http://dx.doi.org/10.20453/reh.v33i3.4938.
Objective
: The objective of this study was to assess the quality of dental medical record keeping at a health center in the city of Ica, Peru.
Material and methods
: We conducted a descriptive study using a quantitative, non-experimental, observational, cross-sectional, and retrospective approach. The sample comprised 212 medical records that were evaluated according to Health Technical Standard No. 029-MINSA/DIGEPRES-V.02. This standard, approved by Ministerial Resolution No. 502-2016/MINSA, allowed for the assessment of various aspects with corresponding scores. After tallying the scores obtained, we ranked the records accordingly.
Results
: The findings revealed that among the medical records at the health center in the city of Ica, 53.8 % demonstrated a need for improvement in quality, 42 % exhibited satisfactory quality, and 4.2 % displayed poor quality.
Conclusions
: The medical records at the Ica health center are in need of improvement for 53.8 % of cases.
Palavras-chave : audit; medical records; quality; diagnosis.
