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[Accurate compiling of the hospital discharge records according to clinicians' perception: critical issues and
Alessandra Mereu1, Sara Frau1, Alessandra Murgia2
1Dipartimento di scienze mediche e sanità pubblica, Università di Cagliari.
Objectives:
to explore clinicians vision on hospital discharge records in order to identify useful elements to foster a more accurate compiling.
Design:
qualitative research with phenomenological approach.
Setting And Participants:
participants were selected through purposive sampling among clinicians of two hospitals located in Sardinia; the sample included 76 people (32 medical directors and 44 doctors in training).
Main Outcome Measures:
identified codes for themes under investigation: vision of accurate compiling, difficulties, and proposals.
Results:
collected data highlighted two prevailing visions, respectively focused on the importance of an accurate compiling and on the burden of such activity. The accurate compiling is hindered by the lack of motivation and training, by the limits of the registration system and the information technology, by the distortions induced by the prominent role of the hospital discharge records in the evaluation processes. Training, timely updating of the information system accompanied by a proper cross-cultural validation process, improvement of the computer system, and activation of support services could promote more accurate compiling.
Conclusions:
the implementation of services, unconnected with evaluation and control processes, dedicated to training and support in the compiling of the hospital discharge records and in the conduction of related epidemiological studies would facilitate the compliance to the compilation. Such services will make tangible the benefits obtainable from this registration system, increasing skills, motivation, ownership, and facilitating greater accuracy in compiling.