Mejora de la calidad del informe clínico de alta hospitalaria desde el punto de vista lingüístico

Abstract

Objectives: The principal aim of this study consists on facilitating the tools to the sanitary personnel in order that written communication improves, specially the medical reports, and bringing the scientific communication over to the patient. It is evident that the more detailed and extensive the study of the medical language is, the more benefits it will bring to the company. Material and methods: Approximately 400 reports of hospitable discharge (IAH) are analyzed from the linguistic point of view. The selection of the material has been carried out by means of a systematic criterion that determines the incorporation in the study of reports that must be written by different physicians of the area of Specialized Medicine of the Public Sanitary System of La Rioja, and the sample includes voluntary discharges, for death, for transfers home or end of cares. In view of the enormous volume of information obtained, the properly philological study centres on the processes of abbreviation. Results: The clinical report is the technical medical document -legally mandatory- that summarises the patient attention and informs about the diagnosis, treatment and recommendations which are to follow. The IAH is the technical medical document -legally obligatory- that summarizes the assistance given to the patient and informs about the diagnosis, treatment and recommendations which must be followed. According to the concrete paragraph, they can be considered to be descriptive, narrative or argumentative texts. In spite of the fact that they depart from a prearranged structure based on a series of imposed items, the format and content of these documents differs in many cases according to the Service and, in occasions, according to the physician. They are mostly written with a technical language based on repetitions of strictly medical structures, without bearing in mind the comprehension of the document on the part of the recipient. Conclusions: The creation of a model of IAH will have to be an interdisciplinary labor and, in order to guarantee its usefulness, the IAH will have to gather, by means of a clear and understandable language, data that are necessary for all those possible recipients of the report; likewise, the rest of factors of the communication will also have an influence on the making of this type of documents, key to the written sanitary communication.