Manejo de la historia clínica por el personal médico y de enfermería de la Fundación Hospitalaria San Vicente de Paul Medellín, Antioquia 1995

Abstract

By means of a descriptive research, the use of the clinic records by the medical and nursing staff from the San Vicente de Paul Hospital Foundation is analysed in order to make suggestion to improve the clinical of the mentioned institution. A no probabilistic sample of histories and a probabilistic sample of the staff were taken; interviewees were slected by a simple random method and it was found that only 13,2% of the staff orders the clinical records, and the updating of care plan was carried out in 100%; no difference on the notes between the auxiliary staff and nurses was found. Concerning the knowleadge of the staff on the rules norms of using the clinic records, 96% of staff states to know the rules. 21,3% ends the evolution notes with name, surname, and code. 85,4% knows the way of following recommendations were suggested: 1). The standardisation of staff knowledge on ordering and taking the correct steps of the clinical records. 2). The implementation of a direct surveillance and control by the committee for clinical records, and 3). The encouraging of a the correct writting of the staff notes by means of courses, seminars and incentives.