Quality of medical record documentation: general internists self-criticism
DOI:
https://doi.org/10.17533/udea.rfnsp.e350725Keywords:
Medical Records, Quality of Health Care, Hospital Information Systems, Electronic Health RecordsAbstract
Objective: to describe the self-critical reflection that internal medicine specialists make on the quality of the information recorded in the electronic medical record in a high complexity hospital.
Methods: qualitative study that applied Grounded Theory techniques, with semi-structured in-depth interviews to fifteen internists of the Pablo Tobón Uribe Hospital in Colombia. The analysis was based on a conceptualization with open coding and then grouping of codes into descriptive categories. Properties and dimensions were identified and related through axial coding with the matrix of the Grounded Theory paradigm, which allowed the emergence of a more abstract category.
Results: the interviewees informed the medical records keeps invaluable and fundamental information which contributes to the improvement of patient´s health. They related the quality of medical records fill out with a national regulatory context, which has administrative and financial challenges that demands external pressure over the completion requirements in the medical assistance. The influence of digital culture and immediacy and insufficiencies skills in undergraduate and postgraduate medical training for a comprehensive fill out medical records, are recognized. The above distances the physician from the patient, generates demotivation in the practice of his profession and makes it easier to make mistakes.
Conclusions: there is a contradiction between the “should be” of the quality of the medical records and what happens in practice, since its original intention of being a tool at the service of clinical care is distorted, as it has become a tool that responds to other external factors to the National health system
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