Evaluación de la calidad de las historias clínicas del área de terapia intensiva de adultos y su impacto en el costo del Hospital Clínica San Francisco.

Abstract

The clinical history is a document that allows adequate follow-up to be provided to patients, this in order to review their evolution. Poor registration can lead to confusion in care and higher hospital costs. The general objective of the present investigation was to evaluate the quality of the clinical records of the intensive care area for adults and the impact it represents on the cost of the Hospital Clínica San Francisco, in order to design improvement plans to optimize the registration of histories. institution clinics. The methodology used maintained a mixed approach with an inductive method. The scope was descriptive, with a non-experimental cross-sectional design. The techniques used were direct observation, interview and survey. An analysis of 275 electronic records revealed problems with the anamnesis, diagnosis, work plan and complete treatment. On the other hand, certain shortcomings derived from the software currently used by the clinic were identified, including the importance of maintaining the complete record of medical records. An upgrade of the system was proposed with an investment of $ 80,000, for which the purchase of equipment, internet plan and training for staff were included. The monthly savings of applying the strategy will be $ 644,000 and the annual savings of $ 7,728,000. It is concluded that the quality of the medical records is low and that the impact on hospital costs is high.