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Inicio Cirugía Española (English Edition) The Importance of the Clinical Report in the Management of a Surgical Unit
Información de la revista
Vol. 91. Núm. 9.
Páginas 617-618 (noviembre 2013)
Vol. 91. Núm. 9.
Páginas 617-618 (noviembre 2013)
Letter to the Editor
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The Importance of the Clinical Report in the Management of a Surgical Unit
Sobre la importancia del informe clínico en la gestión de una unidad clínica quirúrgica
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2623
José María Prieto De Paulaa,
Autor para correspondencia
jmpripaula@yahoo.es

Corresponding author.
, Noelia Sanmamed Salgadoa, José Antonio Otero Rodríguezb, Silvia Franco Hidalgoc, José María Romo Gild
a Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
b Equipo de Atención Primaria Gamazo, Valladolid, Spain
c Servicio de Medicina Interna, Complejo Hospitalario de Palencia, Palencia, Spain
d Servicio de Admisión y Documentación Clínica, Complejo Hospitalario de Palencia, Spain
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Tablas (1)
Table 1. Data to be Included in Clinical Reports at Discharge After Hospitalization (RD 1093/2010).
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Dear Editor,

We have read the article by Gómez et al.1 discussing the importance of high-quality clinical reports in surgical departments. After analyzing the 24 clinical reports of the cases considered outliers by the hospital codification system, the paper reached the conclusion that 58% of the reports either presented insufficient data or are clearly invalid for proper codification. Similar data have been documented on reiterated occasions.2–5

First of all, we would like to congratulate the authors for dealing with an aspect of our healthcare system that is as fundamental as it is generally overlooked. And, although the authors only refer to the discharge reports after a period of hospitalization, we would also like to insist that the comments they make are likewise almost entirely applicable to outpatient consultation reports, which includes approximately 27 million primary consultations annually, a figure that is five times greater than the number of hospital admittances in the Spanish National Healthcare System (SNHS) in 2007.6

We support most of the authors’ affirmations, both with regards to the importance of medical reports as well as the quality issues detected in them. Nonetheless, we would like to make some comments on what we find interesting.

First of all, it is true that the Ministerial Order 221/1984 (6 September)7 established that it is mandatory to fill out discharge reports (including its minimum requirements) after hospitalization for all those patients treated at Spanish healthcare centers. Consequently, this excluded the mandatory requirement for clinical reports in other situations, which are becoming more and more frequent (outpatient consultations, emergency department visits, day hospitalization, ambulatory surgery, etc.).

On the other hand, we feel that what was not made sufficiently clear was the fact that the minimum information that all discharge reports should contain (as well as those from outpatient consultations, the emergency department, etc.) are explicitly defined in Royal Decree 1093/2010,8 which makes their completion mandatory. In addition, this regulation does not regulate (as indicated by the authors in the references) the mandatory completion of the discharge report, but it instead establishes the minimum overall data requirement for clinical reports in the SNHS, which are shown in Table 1 for cases of hospital discharge reports. Furthermore, the regulation in question was the result of professional and institutional consensus.

Table 1.

Data to be Included in Clinical Reports at Discharge After Hospitalization (RD 1093/2010).

Date of the document
Name and surnames of the physician(s) and professional category  Mandatory 
Dates of hospitalization and discharge, and signature  Mandatory 
Department and unit  Mandatory 
Date of the institution
Name of the healthcare service  Mandatory 
Name of the service provider  Recommended 
Name of the center  Mandatory 
Address of the center  Mandatorya 
Data of the patient
Name and surnames  Mandatory 
Date of birth  Mandatory 
Sex  Mandatory 
National identity document/passport  Recommended 
SSANb  Mandatory 
PICc of the autonomous community  Mandatory 
NHS coded  Recommended 
European PIC  Recommended 
Patient file number  Mandatory 
Address  Mandatory 
Telephone  Recommended 
Data of the healthcare process
Reason for dischargee  Mandatory 
Reason for hospitalization  Mandatoryf 
Type of hospitalization (emergency/schedules)  Mandatory 
History  Mandatoryg 
Current symptoms and physical examination  Mandatory 
Summary of complementary tests  Mandatoryh 
Evolution and commentsi  Mandatory 
Main diagnosis  Mandatoryf 
Other diagnoses  Mandatoryf 
Procedures  Mandatoryf 
Treatment  Mandatoryj 
a

E-mail address and website are recommended if they provide information of interest for the patient.

b

SSAN: Social Security affiliation number.

c

PIC: personal identification code.

d

NHS: National Healthcare System.

e

Hospital discharge or transfer to another department, hospital, rehabilitation center, voluntary discharge, death, etc.

f

Recommended for codification (CIE 9 MC/CIE 10/SNOMED-CT, or posterior).

g

Recommended classification in subsections (family history of disease, previous diseases, neonatal, obstetric and surgical history, allergies, addictions, vaccinations, previous medication, social/professional history and functional status).

h

Recommended classification in subsections (laboratory, imaging and other tests).

i

Refers to (apart from the comments regarding the hospitalization period) diagnostic or therapeutic assessments, additional comments, adverse reactions to drugs or surgical protocols.

j

Recommended non-pharmacological indications (oxygen therapy, diet, physical activity) and the active prescriptions at the end of the follow-up period. Mandatory plans of action that are not therapeutic measures themselves (need for follow-up, date of next appointment, etc.).

In a recent article,9 we discussed the responsibilities that are required by all implicated parties (physicians, department/unit heads, politicians, etc.) if what truly matters is quality healthcare and not just apparent formality.

Unfortunately, in light of the article by Gómez et al. as well as others, and more than one year after the autonomous communities should have laid the groundwork to make compliance with the requirements of Royal Decree 1093/2010 possible, it seems that we have not been able to properly respond to what society demands from us.

Thus, we thank the authors for their paper because its objective is to improve the quality of clinical reports and, therefore, the healthcare that we provide. Nonetheless, and regardless of the desirable actions that each healthcare center should carry out to improve the quality of clinical reporting, it is necessary to conclude that by merely complying with the regulations in place, most of the observed deficiencies would not be averted. And this is something that, in addition to being a requirement, we should reflect upon.

We therefore insist that physicians should comply with the legal requirements with regards to clinical reporting, and we concur with the authors about the need for more structured teaching of reporting and greater supervision during the residency period. Along these same lines, it seems important that when the Spanish Society of Internal Medicine workgroup10 defined the competencies for internists, it has included among the core competencies of internal medicine the correct completion of hospital discharge, emergency and outpatient consultation reports in accordance with established standards.

References
[1]
J.C. Gómez Rosado, M. Sánchez Ramírez, J. Valdés Hernández, L.C. Capitán Morales, M.I. del Nozal Nalda, F. Oliva Mompeán.
Importancia de la calidad del informe de alta en la gestión de una unidad clínica quirúrgica.
[2]
J.L. Zambrana, F. Fuentes, M.D. Martín, F. Díez, G. Cruz.
en representación del Grupo para el Estudio de la Actividad de Medicina Interna en Andalucía. Calidad de los informes de alta hospitalaria de los servicios de medicina interna de los hospitales pú blicos de Andalucía.
Rev Calidad Asistencial, 17 (2002), pp. 609-612
[3]
A. Reyes Domínguez, A. Gonzá lez Borrego, M.F. Rojas García, C. Montero Chaves, I. Marín León, J.R. Lacalle Remigio.
Los informes de alta hospitalaria médica pueden ser una fuente insuficiente de información para evaluar la calidad de la asistencia.
Rev Clin Esp, 201 (2001), pp. 685-689
[4]
F. Formiga, P. Dolcet, A. Martínez, J. Mascaró, A. Vidaller, R. Pujol.
Información geriá trica en los informes de alta hospitalaria del servicio de Medicina Interna en pacientes mayores de 65 años.
Rev Clin Esp, 204 (2004), pp. 308-311
[5]
N. Sardá, R. Vilá, M. Mira, M. Canela, M. Jariod, J. Masqué.
Análisis de la calidad y contenido del informe del alta hospitalaria.
Med Clin (Barc), 101 (1993), pp. 241-244
[6]
Ministerio de Sanidad y Política Social. Estadística de establecimientos sanitarios con régimen de internado (indicadores hospitalarios). Año. 2007. Available at: http://www.msc.es/estadEstudios/estadisticas/docs/EESCRI_2007.pdf [accessed: 14 Ene 2011].
[7]
Orden de 6 de septiembre de 1984 por la que se regula la obligatoriedad de los informes de alta.
[8]
Real Decreto 1093/2010, de 3 de septiembre, por el que se aprueba el conjunto mínimo de datos de los informes clínicos en el Sistema Nacional de Salud.
[9]
J.M. Prieto de Paula, S. Franco Hidalgo.
Reflexiones sobre el «conjunto mínimo de datos» de los informes clínicos.
Rev Clin Esp, 212 (2012), pp. 98-103
[10]
J.M. Porcel, J. Casademont, P. Conthe, B. Pinilla, R. Pujol, J. García Alegría.
Competencias básicas de la medicina interna.
Rev Clin Esp, 211 (2011), pp. 307-311

Please cite this article as: Prieto De Paula JM, Sanmamed Salgado N, Otero Rodríguez JA, Franco Hidalgo S, Romo Gil JM. Sobre la importancia del informe clínico en la gestión de una unidad clínica quirúrgica. Cir Esp. 2013;91:617–618.

Copyright © 2013. AEC
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