Accurate compiling of the hospital discharge records according to clinicians’ perception: critical issues and perspectives

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.