Evaluación del expediente clínico integrado y de calidad en pacientes de cirugía programada.

Introduction. The different activities that consist of health care are registered in the medical chart; as well as the quality of the medical institutions is reflected, among other aspects, in the quality of the medical chart. Objective: To determine the quality level of the medical chart of adult patients scheduled for surgery according to the Evaluation Model of the Integrated Medical Chart and of Quality (MECIC in Spanish) in a hospital unit at the third Attention Level. Material and methods. A quantitative, correctional and retrospective study on the services of General Surgery, Neurosurgery and Orthopaedics. The MECIC suitable instrument is integrated by 16 fields. Results. Three out of four parts of the charts fulfill the MECIC requirements. In their field analyses none achieved a 90% or more compliance level; the general level was 70.4%. Out of 12 fields, six managed a superior level of 80%, these were: Reference Note, Social Work, Urgency Note, Recovery Note, Informed Consent and Discharge Note. The fields with 70% compliance were: Pre-anaesthetic Note, Medical History, Pre-surgery Note, Auxiliary Service of Diagnostic and Medical Treatment, Medical Notes and Nursing Note. The fields that have a compliance level of 60% or less are: Records Generalities, Consultation Note and Transfusions Registry. Conclusions. The level of compliance of the medical charts is steady. There are differences in the compliance of the service chart; according to the MECIC, Orthopaedics had 65% of "excellence", Neurosurgery 32% of "good" and General Surgery 82% of "insufficient". The Model of Evaluation of the Integrated Medical Chart and of Quality is a tool that allows the homogenization of the evaluation system of the medical chart. [ABSTRACT FROM AUTHOR]