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Revista Cubana de Medicina

versión impresa ISSN 0034-7523versión On-line ISSN 1561-302X

Resumen

MORENO RODRIGUEZ, Miguel A.; QUINTERO PEREZ, Bárbara; BURUNATE POZO, Mercedes  y  OQUENDO LEON, David. El comentario médico en las evoluciones de las historias clínicas: análisis crítico. Rev cubana med [online]. 1997, vol.36, n.1, pp.18-23. ISSN 0034-7523.

Medical comments from 50 randomly selected medical records of patients who died due to bronchopneumonia at "Carlos J Finlay" Military Hospital during the fist semestre of 1994 were analyzed with the aim of assessing such comments from the qualitative and quantitative point of view. 15,4 % of the reports was considered worthless; 32.9 %. was considered of little worth; 21.3 % was considered as acceptable; 7.4 % as justifying; 18.2 % as useful, and 4.8 % was considered to be rediscussed. A significant difference (p = 0.00024) was found among worthless, acceptable, and of little worth comments in relation to the useful ones and the ones to be rediscussed. The possible causes which may influence on the general poorness of evolutive medical comments is analyzed considering that there is lack of attention, hierarchization and exigency by the chief in charge of basic groups of work, specialists, and residents.

Palabras clave : MEDICAL RECORDS; BRONCHOPNEUMONIA [mortality].

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