Illegible handwriting in medical records.

In clinical records many items are handwritten and difficult to read. We examined clinical histories in a representative sample of case notes from a Spanish general hospital. Two independent observers assigned legibility scores, and a third adjudicated in case of disagreement. Defects of legibility such that the whole was unclear were present in 18 (15%) of 117 reports, and were particularly frequent in records from surgical departments. Through poor handwriting, much information in medical records is inaccessible to auditors, to researchers, and to other clinicians involved in the patient's care. If clinicians cannot be persuaded to write legibly, the solution must be an accelerated switch to computer-based systems.

[Appropriateness of the admissions and stays in an internal medicine department of a secondary hospital using the current version of the AEP ( Appropriateness Evaluation Protocol)]. / Adecuación de los ingresos y estancias en un Servicio de Medicina Interna de un hospital de segundo nivel utilizando la versión concurrente del AEP (Appropriateness Evaluation Protocol).

AIMS: To Study the inappropriateness of the admissions and stays in an Internal Medicine Department using the concurrent version of the AEP (Appropriateness Evaluation Protocol). METHOD: Aplication of the concurrent version of the AEP to all the patients internated in an Internal Medicine Department. 257 RESULTS: 59 patients and 485 stays fulfilled the inclusion criteria. A 15.3/ of the admissions and a 33/ of the stays did not acomplish the criteria of appropriateness of the AEP. The most frequent cause of innappropriate admision was to avoid the delay of the ambulatory studies. The most common cause of innappropriate stay was the wait for results of complementary tests and consultancy between different specialities. CONCLUSIONS: Using the concurrent version of the AEP allows to obtain information about the overuse of the hospitalization resources in an easy and rapid way. The results obtained in our study are similar to other made in Spain using the retrospective version of the AEP.

Adecuación de los ingresos y estancias en un Servicio de Medicina Interna de un hospital de segundo nivel utilizando la versión concurrente del AEP (Appropriateness Evaluation Protocol) / Appropriateness of the admissions and stays in an internal medicine department of a secondary hospital using the concurrent version of the aep (Appropriateness Evaluation Protocol)

Objetivos: Determinar la inadecuación de ingresos y estancias en un Servicio de Medicina Interna utilizando la versión concurrente del AEP (Appropriateness Evaluation Protocol).Método: Aplicación de la versión concurrente del AEP a los pacientes ingresados en un Servicio de Medicina Interna. Resultados: 59 pacientes y 485 estancias fueron evaluados. Un 15.3 por ciento de los ingresos y un 33 por ciento de las estancias fue inadecuado. La causa más frecuente de ingreso inadecuado fue agilización del estudio ambulatorio. El motivo más frecuente de estancia inadecuada fue la espera de resultados de pruebas complementarias e interconsultas. Conclusiones: La utilización de la versión concurrente del AEP permite obtener de forma cómoda y rápida información del sobreuso de los recursos de hospitalización. Los resultados obtenidos son similares a los de otros estudios realizados de forma retrospectiva en España (AU)