ANALYSIS OF THE QUALITY AND THE CONTENT O F HOSPITALARY DISCHARGE REPORTS

BACKGROUND: Hospitalary discharge reports (HDR) are important document s in the data of clinical information of hospital admission. The aim o f this study was to evaluate the completion of the HDR and to know the opinion and usefulness of its content. METHODS: The completion of the different sections of the HDR was analyzed (n = 839) in the hospital of Tortosa (Spain) from January to February 1991. A survey was carried out to primary care physicians (PCP) (n = 81) and to hospital doctors (n = 55) in the same health care region concerning the usefulness, ex tension and content of the HDR. RESULTS: The sections of the HDR which were best filled in were the evolution (88 %), reason for admission ( 91 %) and diagnosis (97 %), and the worst were follow up plans (51 %) and treatment (55 %). With respect to the survey (response rate 71 %), diagnosis (4.9/7), treatment and follow up plan (3.8/7) and reason fo r admission (3.7/7) were the most highly evaluated. CONCLUSIONS: To gu arantee their usefulness, the hospital discharge reports should at lea st collect data concerning the reason for admission, diagnosis, diseas e prognosis, plan for treatment and follow up depicting assistential r esponsabilities of the hospital and primary health care.