Quality of registration of dental medical records in a health center in the city of Ica, Peru
DOI:
https://doi.org/10.20453/reh.v33i3.4938Keywords:
audit, medical records, quality, diagnosisAbstract
Objective: The objective of this study was to assess the quality of dental medical record keeping at a health center in the city of Ica, Peru. Material and methods: We conducted a descriptive study using a quantitative, non-experimental, observational, cross-sectional, and retrospective approach. The sample comprised 212 medical records that were evaluated according to Health Technical Standard No. 029-MINSA/DIGEPRES-V.02. This standard, approved by Ministerial Resolution No. 502-2016/MINSA, allowed for the assessment of various aspects with corresponding scores. After tallying the scores obtained, we ranked the records accordingly. Results: The findings revealed that among the medical records at the health center in the city of Ica, 53.8 % demonstrated a need for improvement in quality, 42 % exhibited satisfactory quality, and 4.2 % displayed poor quality. Conclusions: The medical records at the Ica health center are in need of improvement for 53.8 % of cases.
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