Medical history in the assessment of quality of care in ischemic cardiopathy: is it a valid information source?

To examine the availability of information in the clinical records (CR) to evaluate care quality in ischemic heart disease. A total of 722 clinical records of patients admitted because of ischemic heart disease were evaluated. Based upon a bibliographic review and the criteria of an expert panel necessary data to evaluate care quality were selected. A CR was considered adequate when at least 80% of data considered necessary by the expert panel were available. 78.5% of CR had adequate data. The elderly, clinical presentation as ischemic equivalent and one of the hospitals studied had most deficient CR. The CR is valid to retrospectively evaluate medical care. Differences between hospitals were important and should be taken into consideration before studies on clinical quality are performed.