Cerebrovascular accidents. Case material based on hospital records.

Abstract

Perceiving that inaccuracy of clinical records is the rule rather than the exception, the author examines the data base of the Amarante Regional Hospital with particular relevance to the patients who were hospitalized with cerebral vascular accident (CVA) in the Department of Internal Medicine during 1990, 1991 and 1992. The objective is to view the existing computerised hospital database as a source of information for future studies within the clinical field and, at the same time, to be aware of the department's casuistry and to contribute to the epidemiological understanding of the population who lives in the area of influence of this hospital. In this department, 24% of all the hospitalised patients had either a recent CVA or had already had one previously. On the whole, the disease affected both sexes in an equal manner, but females later than males. The mortality rate was greater in patients with CVA (17%) than in those without CVA (9%) and was also greater in CVA-females (19%) than in CVA-males (15%). The intercurrences in the community were the cause of admission in 26% of the hospitalised patients with a CVA, and were mainly respiratory, metabolic and urinary diseases, and appeared to be more serious in males. The mortality rate in patients with intercurrences (19%) was only exceeded by that caused by hemorragic accidents (22%). The author examines and discusses the instances of error during the construction and data gathering of the database and draws his own conclusions.