[The quality of the discharge reports from the internal medicine services of Castilla-La Mancha (a structural evaluation)].

The discharge report is one of the final outputs of the health care activity. We have tried to analyze several aspects related to its quality. For this purpose, we conducted a cross-sectional study analyzing 800 reports of patients admitted in the services of Internal Medicine at 6 hospitals of Castilla-La Mancha during the year 1991. We must stress the absence of discharge reports for death patients and the failure to record drug allergies (69.9%), medical history (10.4%) and time of evolution of the disease (16.9%), as well as treatment in 17 reports out of 781 and follow-up review after discharge in 12.8%.

CONCLUSIONS

Discharge reports have a low scientific content and the production of this type of records is not a routine practice in the case of death patients.