[Quality of hospital discharge reports in terms of current legislation and expert recommendations]

Abstract

Objective: To determine the quality of hospital discharge reports (HDRs) taking into account current legislation and the conclusions of the consensus on hospital discharge reports in medical specialities in 11 community hospitals in Andalusia (Spain).

Material and methods: A cross-sectional study of 1,708 HDRs was carried out. We determined the presence or absence of the various items required by current legislation and by the recommendations of the above-mentioned consensus.

Results: A total of 97.4% (95% confidence interval [95% CI]: 96.5-98.2) of the HDRs were classified as satisfactory according to the stipulations of current legislation. However, when the assessment was based on the consensus, the rate of adequacy fell to 72.1% (95% CI: 70.0-74.3). A notable finding was the absence of the duration of treatment after hospital discharge in 39.4% of the HDRs.

Conclusions: HDRs show an excellent level of compliance with the data required by current regulations, but their intrinsic quality needs to be improved.

Keywords: Calidad; Discharge reports; High-resolution hospitals; Hospitales de alta resolución; Informes de alta; Quality.