QUALITY OF DOCUMENTATION IN MEDICAL REPORTS OF DIABETIC-PATIENTS

In a retrospective analysis of 752 consecutive medical reports of pati ents with insulin- or noninsulin-dependent diabetes mellitus, we inves tigated the completeness of documentation of indicators of quality of care, The medical reports are the currently used form of documentation which is sent to the General Practitioner after the patient's dischar ge from hospital, The indicators of care were data on clinical history , physical examination, laboratory results and secondary complications . The documentation was incomplete; e.g. in 8.0% of insulin-dependent (IDDM) and in 26.4% of non-insulin-dependent diabetics (NIDDM), HbA1c was missing, In 7.6%, the type of diabetes was not stated, The frequen cy of recorded secondary complications was lower than it has to be exp ected considering metabolic control and duration of diabetes of the st udied group, Documentation was more complete for IDDM patients, The re ports of NIDDM patients with incipient or overt diabetic nephropathy r evealed less frequent recordings of data on lipid metabolism and blood pressure compared to the group without nephropathy. The documentation of indicators of quality of care in medical reports for general pract itioners is incomplete for many diabetic inpatients, Standardized meth ods of documentation are required urgently, Copyright (C) 1996 Elsevie r Science Ltd.