Efectividad de la auditoría sobre la calidad del llenado del formulario HCU_008, en el Servicio de Emergencia del Hospital Luis Vernaza

Abstract

Abstract: Introduction: The medical history is an essential document in the process of patient care, necessary to achieve timely diagnoses and treatments, and avoid the presentation of complications and sequelae in patients. Objective: Determine the effectiveness of the audit on the quality of filling out the form HCU_008, in the emergency at the Luis Vernaza Hospital. Methods: Observational, analytical, cross-sectional study, in which two Form groups: those in which an on-site audit is performed to verify the quality of filling out the HCU_008 form and those in which said control is not carried out. Patients admitted through the emergency service of the Luis Vernaza Hospital will be analyzed. in a period of three months. Results: A considerable increase in the quality of filling is observed among non-HC audited with respect to the audited, 48% of audited forms are in accordance with the diagnosis and treatment. A notable increase is observed in the correct registration of variables of the audited HC in relation to the unaudited HC, 64% are described correctly.