[Importance of the quality of the discharge report in the management of a surgical clinical unit].

Background: The discharge report is a basic document at the end of a care process, and is a key element in the coding process, since its correct wording, reliability and completeness are factors used to determine the hospital production.

Material And Methods: From a hypothesis based on the analysis of the consistency between the discharge report and data collected from the routine clinical notes during admission, we should be able to re-code all those mis-coded, thus placing them in a more appropriate diagnosis-related group (DRG). A total of 24 patient outliers were analysed for the correct filling in of the type and reason for admission, personal history, medication, anamnesis, primary and secondary diagnosis, sugical procedure, outcome, number of diagnostic and procedures cited, concordance between discharge report and history and recoding of the DRG.