Quality of Documentation in Medical Reports of Diabetic Patients

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Abstract
In a retrospective analysis of 752 consecutive medical reports of patients with insulin- or non-insulin-dependent diabetes mellitus, we investigated the completeness of documentation of indicators of quality of care. The medical reports are the currently used form of documentation which is sent to the General Practitioner after the patient's discharge from hospital. The indicators of care were data on clinical history, physical examination, laboratory results and secondary complications. The documentation was incomplete; e.g. in 8.0% of insulin-dependent (IDDM) and in 26.4% of non-insulin-dependent diabetics (NIDDM), HbA1c was missing. In 7.6%, the type of diabetes was not stated. The frequency of recorded secondary complications was lower than it has to be expected considering metabolic control and duration of diabetes of the studied group. Documentation was more complete for IDDM patients. The reports of NIDDM patients with incipient or overt diabetic nephropathy revealed less frequent recordings of data on lipid metabolism and blood pressure compared to the group without nephropathy. The documentation of indicators of quality of care in medical reports for general practitioners is incomplete for many diabetic inpatients. Standardized methods of documentation are required urgently.

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