[The quality of the discharge reports from the internal medicine services of Castilla-La Mancha (a structural evaluation)].

UNLABELLED

The discharge report is one of the final outputs of the health care activity. We have tried to analyze several aspects related to its quality. For this purpose, we conducted a cross-sectional study analyzing 800 reports of patients admitted in the services of Internal Medicine at 6 hospitals of Castilla-La Mancha during the year 1991. We must stress the absence of discharge reports for death patients and the failure to record drug allergies (69.9%), medical history (10.4%) and time of evolution of the disease (16.9%), as well as treatment in 17 reports out of 781 and follow-up review after discharge in 12.8%.

CONCLUSIONS

Discharge reports have a low scientific content and the production of this type of records is not a routine practice in the case of death patients.