Evaluación de la calidad de la información registrada en las historias clínicas en AS-400 del área de emergencia del Hospital General de Guayaquil IESS – Los Ceibos.

Abstract

The general objective of this work is to evaluate the information recorded in the medical records in AS/400 in the emergency area of the General Hospital of Guayaquil IESS Los Ceibos, through the qualitative and quantitative review of the processed data, to improve the quality of the registers. It is a descriptive, documentary and analytical type of research, with a mixed approach; Techniques such as the survey and the interview are used, which allowed knowing the opinions of the personnel who work in the emergency area. The study population was made up of two groups, a group represented by the staff of the emergency area and another population with the medical records evaluated, in a sample of 362 medical records. The registry of the initial data, the diagnostic methodology, the follow-up of the patient's health problems, the nursing records, and other data were reviewed. As main results, it was obtained that, on average, 155 clinical histories did not present registered data in some required fields, 109 histories presented incomplete records and only an average of 98 clinical histories presented complete data. Finally, strategies are proposed that contribute to improving the quality of the records in the medical records of the emergency area of the Hospital.