Document Detail

[Importance of the quality of the discharge report in the management of a surgical clinical unit].
MedLine Citation:
PMID:  23337325     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: The discharge report is a basic document at the end of a care process, and is a key element in the coding process, since its correct wording, reliability and completeness are factors used to determine the hospital production.
MATERIAL AND METHODS: From a hypothesis based on the analysis of the consistency between the discharge report and data collected from the routine clinical notes during admission, we should be able to re-code all those mis-coded, thus placing them in a more appropriate diagnosis-related group (DRG). A total of 24 patient outliers were analysed for the correct filling in of the type and reason for admission, personal history, medication, anamnesis, primary and secondary diagnosis, sugical procedure, outcome, number of diagnostic and procedures cited, concordance between discharge report and history and recoding of the DRG.
RESULTS: From a total of 24 episodes, 6 had precise and valid reports, 4 were valid but not precise enough, 9 were insufficient, and 5 were clearly invalid. The recoded DRG after the documentation review was not significantly different, according to the Wilcoxon test, being changed in only 5 cases (P = .680).
CONCLUSION: Quality in discharge reports depends on an adequate minimum data set (MDS) in concordance with the source documentation during admission. Discordance can change the DRG, despite it not being significantly different in our series. Self-audit of discharge reports allows quality improvements to be developed along with a reduction in information mistakes.
Juan-Carlos Gomez-Rosado; María Sanchez-Ramirez; Javier Valdes-Hernandez; Luis C Capitan-Morales; Marta I Del-Nozal-Nalda; Fernando Oliva-Mompean
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Publication Detail:
Type:  English Abstract; Journal Article     Date:  2013-01-19
Journal Detail:
Title:  Cirugía española     Volume:  91     ISSN:  1578-147X     ISO Abbreviation:  Cir Esp     Publication Date:    2013 Jun-Jul
Date Detail:
Created Date:  2013-06-18     Completed Date:  2014-06-08     Revised Date:  2014-10-28    
Medline Journal Info:
Nlm Unique ID:  1254104     Medline TA:  Cir Esp     Country:  Spain    
Other Details:
Languages:  spa     Pagination:  378-83     Citation Subset:  IM    
Copyright Information:
Copyright © 2012 AEC. Published by Elsevier Espana. All rights reserved.
Vernacular Title:
Importancia de la calidad del informe de alta en la gestión de una unidad clínica quirúrgica.
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MeSH Terms
Diagnosis-Related Groups
Hospital Units / organization & administration*
Medical Records / standards*
Patient Discharge*
Quality Control
Surgery Department, Hospital / organization & administration*
Surgical Procedures, Operative*
Comment In:
Cir Esp. 2014 Oct;92(8):574-5   [PMID:  24947839 ]

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