Efectividad de la evaluación de historias clínicas informatizadas en un hospital universitario

Abstract

Objective

The objective of this study was to evaluate a sample of electronic medical records (EMR) that was sufficiently representative of the different areas of care in a university hospital, as well as to verify the effectiveness of an initial intervention through a second evaluation.

Methods

Medical records audits were performed in 2012 and 2013 by a blind peer review of random samples of care episodes, proportional to the activity of each clinical department, and with the same evaluation method being applied to all of them.

Results

More than 1,000 episodes of care were reviewed in the 2 audits. A significant improvement was found in hospital admissions (P=.000) in all the sections of the EMR analysed (P=.002), and was especially significant for the reason for consultation, for which its completion increased by 8.5% (p<.05), and also in the sections of the current process record (7.1%), physical examination (4.7%), allergies (3.9%), and clinical course (3.6%). The assessment of the discharge report, as a whole, showed an improvement (P=.001). In outpatient follow-up visits, a significant positive improvement was observed in the 4 sections evaluated (P<.05), and also overall (P=.000).

Conclusions

According to study conditions, the dissemination of the results was effective in improving the quality of the EMR. The results have made it possible to implement actions to review the work processes in certain departments, and also the partial redesign of the interface on being a reproducible methodology accepted by the organisation.