Evaluación de la calidad del llenado del formulario 053 de derivación en el servicio de hospitalización del ISSFA Regional Litoral durante el periodo octubre 2025 a marzo 2026

Abstract

Abstract: Form 053 contains medical and administrative information needed to manage the referrals of patients between health facilities. The goal was to evaluate the quality of filling out the form in the hospitalization service of ISSFA Regional Litoral from October 2025 to March 2026. A quantitative, observational, descriptive, retrospective, and cross-sectional study was conducted. The sample included 341 Form selected through simple random sampling. Data were collected using a structured checklist and analyzed through absolute frequencies and percentages. The main inconsistency was the incomplete summary of the clinical picture (7,3%), followed by a lack of clarity in the reason for referral (4,1%). Other issues identified were missing medical signature (2,3%), legibility problems (2,1%), absence of an ICD-10 diagnosis (1,8%), and missing medical stamp (1,5%); no erasures or corrections were found. Compliance with the evaluated regulatory criteria was 88,9% for AM No. 00115-2021 and 100% for AM No. 00140-2023. The conclusion was that the main opportunities for improvement are related to completing the clinical summary and clarifying the reason for referral.