Introduction:

To analyze the quality of the medical records of patients admitted to the Gafrée e Guinle University Hospital.

Methods:

A total of 100 medical records were randomly selected from the Medical and Surgical Clinics of hospitalized patients at Gaffrée and Guinle University Hospital. The analysis of medical records consisted in the absence or presence and, if present, whether the following items are adequate or inadequate: patient identification file; medical report; hospitalization and discharge reports; hospital admission summary; medical evolution report; nursing evolution report; medical prescriptions; operative report; anesthesia report; histopathological test report. In the Medical Clinic records the operative and anesthesia reports, histopathological test report and other topics related to surgery were excluded. In each medical report it was verified whether the aforementioned items were present, correctly filled out, using legible handwriting, and whether there were inadequate abbreviations, symbols and signs. The results were compared in both clinics to analyze which service showed the best performance. To evaluate the performance of the hospital, all items were analyzed for their presence or absence, whether were adequate or inadequate and not applicable. Data analysis was performed using tables and graphs, and the statistical analysis was performed by the non-parametric Mann-Whitney Test.

Results:

Not all items were found nor filled out, in addition to their lack of order. Of the total analyzed sample 85.5% were legible and 32% were considered inadequate, being 37 medical records from the Surgical Clinic and 27 from the Medical Clinic. The results of the additional tests were found in only 55.5% of the sample.

Conclusion:

The formulation of Gaffrée and Guinle University Hospital medical records is inadequate, showing multiple incomplete and/or absent items.

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