Characterization of reported diagnostics in medical records and tally with the presumptive diagnosis issued, by characteristics of evaluation for physical therapy and neurorehabilitation Caracterización de diagnósticos reportados en las historias clínicas y su concordancia con el diagnóstico presuntivo emitido, según las características semiológicas de la evaluación por fisioterapia y neurorehabilitación

Abstract

Introduction: The research was based on the revision of reported diagnoses, then a clinical evaluation of the patients based on clinical results was used. The report was corroborated and a diagnosis associated with the semiology that was found for each child who is enrolled at the Instituto técnico Guaimaral Sede Alma Luz Vega of Cúcuta Finally, a percentage was analyzed to investigate if there was any diagnostic error found in that investigation. Objective To characterize the reported diagnoses in the personal stories of the ones who were evaluated and their concordance with the presumptive diagnosis, according to the semiological features of the evaluation by Physiotherapy and neurorehabilitation. Results: It was identified that in the 100% of the cases there were found two or more diagnoses per person; there were 90 different diagnoses which were reported, they present an amount of 0.82 diagnoses in the whole population, referring in some cases that the manifestations of a pathology have been stablished as a diagnostic.