Evaluation of medical death records and the death records committee of the Gafreé and Guinle University Hospital (HUGG)

Abstract

Objectives: Analyze qualitatively and quantitatively the death records from medical records of the Surgical Clinic and Medical Clinic services of the Gaffrée and Guinle University Hospital (HUGG) comparing the results. Evaluate the presence of analysis by the Deaths Revision Comission and compare with the records not evaluated by it. Methods: The auditor analyzed medical records of patients who died in the HUGG randomly. The diagnoses and causes of death mentioned in the death certificate were identified and compared, even as verifying the analysis of the Death Review Commission, as well as adequacy according to the booklet “The Death Certificate” of the Health Ministry, classifying in “satifactory” or “no satisfactory”. Results: At total 350 medical records of hospitalized patients who died at HUGG were analyzed. About 22% of death certificates did not have any cause of death. Of these, 22 remained unfilled even after analysis by the Death Review Commission. Of the total collected, approximately 52% of the samples were classified as “unsatisfactory”. Conclusions: Most of the medical records presented the necessary diagnoses to identify the underlying cause of death, despite the significant number of records with no Deaths Certificate filling. In addition, the great variability of writings made it difficult to identify the causes of death and correctly fill in the DC. Finally, there was a predominance of death registration that do not adequately correspond to the standard recommended by the MS booklet.