BACKGROUND: Hospitalar discharge reports (HDR) are important documents in the data of clinical information of hospital admission. The aim of this study was to evaluate the completion of the HDR and to know the opinion and usefulness of its content.METHODS: The completion of the different sections of the HDR was analyzed (n = 839) in the hospital of Tortosa (Spain) from January to February 1991. A survey was carried out to primary care physicians (PCP) (n = 81) and to hospital doctors (n = 55) in the same health care region concerning the usefulness, extension and content of the HDR.RESULTS: The sections of the HDR which were best filled in were the evolution (88%), reason for admission (91%) and diagnosis (97%), and the worst were follow up plans (51%) and treatment (55%). With respect to the survey (response rate 71%), diagnosis (4.9/7), treatment and follow up plan (3.8/7) and reason for admission (3.7/7) were the most highly evaluated.CONCLUSIONS: To guarantee their usefulness, the hospital discharge reports should at least collect data concerning the reason for admission, diagnosis, disease prognosis, plan for treatment and follow up depicting assistent responsibilities of the hospital and primary health care.
Forms and Records Control Humans