THE EFFECT OF COMPLETENESS OF MEDICAL RECORDS ON THE DETERMINATION OFAPPROPRIATENESS OF HOSPITAL DAYS

Although the Appropriateness Evaluation Protocol (AEP) has been widely used during the past decade, several methodological concerns have not yet been properly resolved, including the possible influence of low c ompleteness of the medical records on the results yielded by the AEP i n retrospective studies. We examined medical records for a random samp le of 345 patient-days with the AEP, according to a protocol that incl uded several variables potentially related to inappropriateness. The c ompleteness of physician and nursing notes was also assessed, The prop ortion of inappropriate days of hospitalization was 36.2%, In the crud e analysis, significantly higher proportions of inappropriateness were found for lower values of completeness, Factors related to the inappr opriateness of stay were summer season, elective admission, no previou s admissions, surgical and medical-surgical service in charge, and the day sampled falling within the last third of the hospital stay. Adjus tment for the completeness level of medical records did not substantia lly change the strength of the association between these factors and t he inappropriateness of hospital stay, Completeness level itself did n ot show any significant association with the proportion of inappropria te days in the adjusted analysis.