Revista Brasileira de Epidemiologia
Print version ISSN 1415-790X
PAVAO, Ana Luiza Braz et al. Incidence of in-hospital adverse events in the State of Rio de Janeiro, Brazil: Evaluation of patient medical record. Rev. bras. epidemiol. [online]. 2011, vol.14, n.4, pp.651-661. ISSN 1415-790X. http://dx.doi.org/10.1590/S1415-790X2011000400012.
OBJECTIVE: To evaluate the quality of information obtained from medical records of three teaching hospitals in the State of Rio de Janeiro, Brazil, which participated in a previous study on the incidence of adverse events (AE). METHODS: Descriptive study based on the information collected from medical record review during the incidence study. An evaluation score of completeness, measuring the proportion of absent information was applied, based on the following items: excellent (less than 5%), good (5% - 10%), moderate (11% - 20%), bad (21% - 50%), and very bad (more than 50%). Proportions and 95%confidence intervals were calculated for each variable obtained from medical records. Analysis was developed for the whole group of patients, by hospital groups, and by patients with and without AE. For analyzing the group of variables, means were estimated and the t-student's test was applied for comparisons. The Chi-squared test and Fisher's statistics were applied for comparing patients with and without AE. RESULTS: The quality of information obtained from patient medical records was considered bad in the group of patients as a whole. Variables with the highest proportion of absent information were: "Nurse's first evaluation of the patient" (63.9%) and "Social worker's evaluation" (80%). Hospital 3 had the best results in terms of quality of medical records and hospital 1 had the worst results. The quality of medical records of patients with AE was better than the quality of medical records of patients that had no AE. CONCLUSIONS: Variables considered essential for patient's healthcare were not well documented. Measures to develop quality of medical records are necessary to improve patient's healthcare.
Keywords : Medical Records; Quality; Healthcare; Health Services; Adverse Events; Patient Safety.