Abstract
The medical record is a basic document in healthcare that permeates all assistance, administrative, research and teaching activities, in addition to allowing communication between health professionals. However, we should emphasize the difference in the quality of these records produced by different institutions. This study aimed to analyze the quality of this data in a teaching hospital in the city of Mogi das Cruzes, São Paulo, Brazil. A total of 191 medical records dated from 2016 were included in the evaluation, which consisted in applying an instrument that ascribe a score to each obligatory item in the medical record. Although the total scores obtained were not low, the results show that the quality of medical records varies, and that the teaching hospital should improve how they are filled out.
Keywords:
Medical records; Education, medical; Codes of ethics