Revista Clínica Española Revista Clínica Española
Rev Clin Esp 2001;201:563-7 - Vol. 201 Núm.10
La historia clínica en la evaluación de la calidad asistencial de la cardiopatía isquémica: ¿es una fuente de información válida?
The clinical record in the evaluation of care quality in ischemic heart disease: is it a valid information source?
A. Reyes Domíngueza, A. Palma Amaroa, G. Montero Chavesa, M F. Rojas Garcíaa, M J. Pérez Lozanoa, I. Marín Leóna, J R. Lacalle Remigioa
a en representaci??n del Grupo de Estudio de la Calidad Asistencial (GRECA)
Resumen
Objetive. To examine the availability of information in the clinical records (CR) to evaluate care quality in ischemic heart disease. Material and methods. A total of 722 clinical records of patiens admitted because of ischemic heart disease were evaluated. Based upon a bibliographic review and the criteria of an expert panel necessary data to evaluate care quality were selected. A CR was considered adequate when at least 80% of data considered necessary by the expert panel were available. Results. 78.5% of CR had adequate data. The elderly, clinical presentation as ischemic equivalent and one of the hospitals studied had most deficient CR. Conclusions. The CR is valid to retrospectively evaluate medical care. Differences between hospitals were important and shoul be taken into consideration before studies on clinical quality are performed.
Palabras clave
historia clínica, colección de datos, auditoría médica, evaluación de procesos, cardiopatía isquémica
Keywords
Clinical record, data collection, medical audit, evaluation of procedures, ischemic disease
Rev Clin Esp 2001;201:563-7 - Vol. 201 Núm.10