Valutazione della qualità delle schede di dimissione ospedaliera

Objectives: To verify the Hospital Discharge Records (SDO) reliability and completeness as informative tool in order to improve Health Cares. Methods: We carried out the activity in two Care Units, during two years. 632 SDO have been sampled out of the total of 3,004. A careful revision of the medical records and the SDO recompilation by the Health Management and it’s comparison with the SDOs from the Units were carried out to roll out possible errors in compilation. Results: The error percentage ranged between 54.1 and 68.4 according to the examined variable. The most common error was the lack of secondary diagnosis. The SDO revision has allowed an increment of quality markers (mean number of diagnosis +63%, mean number of interventions and/or procedures +17%, case-mix index +17%) as well as an incremental gain of 5.2%. Conclusions: The present study has shown that it is necessary giving reater care in the SDO compilation, to increase the real quality of the work performed and improving the available sources for Health Services.