Comparison and combination of three data sources from patient medical records to determine optimal quantification of postoperative morbidity according to the Clavien Dindo Classification and the Comprehensive Complication Index. A prospective study

[Display omitted] It is currently unknown which data sources from the clinical history, or combination thereof, should be evaluated to achieve the most complete calculation of postoperative complications (PC). The objectives of this study were: to analyze the morbidity and mortality of 200 consecutive patients undergoing major surgery, to determine which data sources or combination collect the maximum morbidity, and to determine the accuracy of the morbidity reflected in the discharge report. Observational and prospective cohort study. The sum of all PC found in the combined review of medical notes, nursing notes, and a specific form was considered the gold standard. PC were classified according to the Clavien Dindo Classification and the Comprehensive Complication Index (CCI). The percentage of patients who presented PC according to the gold standard, medical notes, nursing notes and form were: 43.5%, 37.5%, 35% and 18.7% respectively. The combination of sources improved CCI agreement by 8%–40% in the overall series and 39.1–89.7 % in patients with PC. The correct recording of PC was inversely proportional to the complexity of the surgery, and the combination of sources increased the degree of agreement with the gold standard by 35 %–67.5% in operations of greater complexity. The CDC and CCI of the discharge report coincided with the gold-standard values in patients with PC by 46.8% and 18.2%, respectively. The combination of data sources, particularly medical and nursing notes, considerably increases the quantification of PC in general, most notably in complex interventions. Actualmente se desconoce, qué fuentes de datos de la historia clínica o combinación de ellas se deben evaluar para conseguir el cómputo más completo de las complicaciones postoperatorias (CP). Los objetivos de este estudio fueron: analizar la morbimortalidad de 200 pacientes consecutivos sometidos a cirugía mayor y definir qué fuentes de datos o combinación de ellas recogen la máxima morbilidad y, determinar la exactitud de la morbilidad reflejada en el informe de alta. Estudio de cohorte observacional y prospectivo. Se consideró Gold-Standard la suma de todas las CP encontradas en la revisión combinada de evolutivos médicos, de enfermería y formulario específico. Las CP se clasificaron según la Clasificación de Clavien Dindo y el Comprehensive Complication Index (CCI) El porcentaje de pacientes que presentaron CP según el Gold-Standard, las notas médicas, de enfermería y formulario