Management of The Clinical Record in A Second Level Hospital, Puebla, México
Introduction. Proper management of the clinical record in hospitals is essential to provide quality medical care.
Objective: To evaluate the management of the clinical record using indicators of the Integrated and Quality Clinical Record Evaluation Model (MECIC) and Integral System Model in Health for the Evaluation of the Quality and Safety Committeein a second level hospital in the city of Puebla, Mexico.
Material and Methods: Observational, transversal study, diagnosis. Interviews were carried out with the personnel responsible for the clinical file, and a previously validated questionnaire was applied to 93 doctors from the three-shift outpatient clinic.
Results: Percentages of response to questions applied to outpatient physicians and who answered to fully agree: ¿Receive clinical records on time? 14 %, ¿Are the clinical records complete and orderly? 6%, ¿The clinical records is in good condition? 3%, ¿Is the electronic medical record necessary? 24% y ¿Do you agree with the functioning of the clinical record committee? 10%. Responses from the Clinical File Coordinator: From the first questionnaire on evidence of follow-up of the clinical records committee, 28.57% of activities are performed. Of the second questionnaire on custody, conservation and archiving of the clinical file, 83.33% are met.
Conclusion: The percentages on the five questions asked to the doctors are low, the answer on the necessity of the use of the electronic medical record was 24%. The answers of the person in charge of the clinical file show deficiency in the functions of the clinical file committee and on custody conservation and archiving 83.33% are fulfilled, it is to draw attention that the negative answers refer to lost files.
Key words: Clinical Records, Clinical File, Hospitals.