The customer or patient record, also called medical record, is a fundamental element for providing good patient care, an instrument for permanent education and research, besides serving a variety of hospital management-related purposes. This study appraised the record models used at 77 (73.3%) of the 105 hospitals belonging to the Brazilian Association of University and Teaching Hospitals (Abrahue) by estimating scores for several of their items or parts of them regarding the clinical histor y and evolution of the patient. The predominating kind of record (92.2%; n = 71) was the one written on paper, none was elaborated in electronic format. Comparing the records of public hospitals (n=54) with those of philanthropic hospitals (n = 23), the records of the public hospitals reached higher scores (p<0.05), but in both cases the total of studied items showed low scores. With respect to the items composing the anamnesis for instance, while the expected maximum score was 22, the mean was 4.3 (± 3.7), with limits of 0 and 15 and a median of 4. In conclusion, further to the limited quality of most of the studied records, almost none of them had incorporated the modern technologies offered by the information sciences.
Hospitals, University; Medical Record; Education, Medical
