LEGIBILITY OF THE REPORTS OF EPICRISIS OF THE DECEASED PATIENTS IN A

DEPARTMENT OF INTERNAL MEDICINE: A PRESCRIPTION FOR CLARITY?

F. J. Rodriguez-Vera, M. Eusebio, Luisa Arez, M. Cesar, R. Tome

Department of Internal Medicine. Hospital do Barlavento Algarvio

Portimão. Portugal. EU

INTRODUCTION

Legibility is a necessary perquisite for appropriately assessing clinical records.

A periodical assessment of the clinical records of the patients deceased in a ward is necessary to detect avoidable situations and predictors of in hospital death

OBJECTIVE

To study the accessibility to the information contained on the reports of epicrisis of the

deceased patients in our Department of Internal Medicine.

MATERIAL AND METHOD (I)

Randomized sample of patients died in the Department of Internal Medicine during 2003External assessment of the quality of writing.Variations of legibility depending on:

Average stay before deathDay of the week of the decease

1. Illegible

2. Some words are legible, but the whole is unclear

3. Some words are legible, and the whole makes sense

4. Some words are not legible

5. All the words are legible

MATERIAL AND METHOD (II)Scores for legibiilty

RESULTSN= 182Sample=108Average age=74,13 yrsAverage stay 11,02 d

64%

36%MaleFemale

Writing doctors =13

RESULTS (II)

102

6

0

20

40

60

80

100

120

Handwritten Typewritten

Typewritten

Handwritten

312%

416%

571%

21%

10%

12345

RESULTS (III)Distribution by legibility

Homogeneous distribution by days of the weekLegibility and stay

25%>5 days (N=60)

31,81%<5 days (N=48)

Legibility= or <4 (%)Stay

RESULTS (IV)

• The percentage of defects of legibility of the epicrisis of the deceased patients is high. Such defects could eventually be corrected by the adoption of a computerized model for such reports.

• The present system of absence of medical staff in the ward during the weekend does not seem to influence either mortality or quality of the correspondent epicrisis

CONCLUSIONS (I)

3. The reports of those patients with shorter average stay seemed to have worse legibility. This fact might be due to, among other causes, a lower personal implication with the patient.

CONCLUSIONS (II)