Reflexiones sobre el «conjunto mínimo de datos» de los informes clínicos

Abstract

Royal Decree 1093/2010 (3 September 2010) establishes the minimum data set that the clinical reports of discharges and outpatient visits elaborated in the facilities of the National Health System should contain, among others.Until then, the Ministerial Order 221/1984, that only required the drawing up of a discharge report for patients seen in a hospital-regime health care establishment, was in force.In spite of the importance of these documents, their quality is far from that desired, especially that of the reports on visits, which, among other things, are not performed in a high percentage of the cases.Recently the Sociedad Española de Medicina Interna (SEMI) (Spanish Society of Internal Medicine), in collaboration with other scientific societies, issued some recommendations for the drawing up of the discharge reports.In this present work, a series of thoughts are made on the implications of the new decree, especially in the case of the reports of the outpatient clinics.