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[Consistency and validity of the evaluation of the clinical chart]
S Navarrete-Navarro1, G A López-García, J F Hernández-Sierra
1Unidad de Epidemiología Hospitalaria, C.M.N., SXXI, IMSS.
Objective:
Assess the degree of external consistency and validity of the EXP CLIN instrument has for measuring the quality information contained in medical charts.
Material And Methods:
In a transverse comparative study, two hundred and twelve clinical charts were randomly selected belonging to patients seen at a pediatric hospital. The charts were assessed using the EXP-CLIN for phases: 1) internal assessment: by hospital personnel of the pediatric hospital, and, II) external assessment: by personnel from other hospitals. The results were analyzed using the concordance method.
Results:
The concordance percentages were found to be 76% for medical charts and medical notes related with the process of diagnosis-treatment, as well as the general characteristics of the clinical chart. The concordance percentages average was 88%, supporting the idea that when the EXP-CLIN instrument is applied twice to the same chart, good concordance is obtained between the two measures.
Conclusions:
Given that the application of the instrument documented a good level of external consistency, its use is justified for assessing the quality of the information contained in the charts of the patients seen at our unit.