Quality of the clinical process – comparative study 2004-2005

Abstract

Background: to provide a quality service is crucial to understand the
need for change. A different approach of those procedures and results
implies an involvement and a motivation of Health Care professionals. The
performance of a Health Service is nowadays linked to the level of access
and organization of the clinical information. In such context, a correct
and complete documentation of the patient’s clinical data is essential
for the practice of a quality Medical care, being the clinical record the
basis of a hospital management and structure.
Aim: the endpoint of this work was to compare 2004 and 2005 regarding the quality criteria of medical records, proposed with predefined
variables, to determine the rate of achievement.
Material and Methods: a descriptive and transverse observation study
based on the medical record of each patient, referring to the year 2004
and to the year 2005. The predefined variables were the existence of a
classic clinical history, the ward admission notice, the hospital discharge
notice, the patient’s problems list, based on Weed’s method and the
record of laboratorial analysis on a specific registration sheet. The reasons why the hospitalization was extended where also assessed not only
measuring it but also identifying the causes of such delay. There were
a total of 1031 (F554; M507) patients admitted in 2004 with a mean
age was 70 years [15-103] and the average hospitalization period was
7,6 days [1-78]. In the year of 2005 there were a total of 1030 (F531;
M499) patients admitted, with a mean age of 71 years [16-99] and the
average hospitalization period was 8 days [1-101].
Results: In both years, 2004 and 2005, the admission notice was recorded in 100% of patients, excluding the cases where the Clinical History
was recorded. With exception of patients deceased and transferred to
other services, the Discharge Notice was also complied with in 100% of
cases. The classical clinical history was made in 213 patients (21%) in
2004 and in 87 patients (8.5%) in 2005. The laboratory analysis sheet
and the Weed’s list were recorded in 866 (84%) and 847 patients (82%)
in 2004 and in 898 (87%) and 863 patients (84%) in 2005, respectively.
The extended hospitalization was verified in 11% and 9% of the patients
(2004 and 2005), respectively; the social problems were the major causes
in the first year and the clinical problems in the second.
Conclusion: regarding the clinical record we consider very positive the
results achieved. However it is a reason for concern the limited number
of Clinical Histories recorded, as well as its reduction when compared to
2004. On the extended hospitalization on Medicine 1 ward, the clinical
issues are as important as the social ones. We also find that the implementation of structured assessment forms impact the clinical practice
promoting a higher standard quality