Aguado Mingorance J A, Gastón Morata J L, Bueno Cavanillas A, López Gigosos R, Rodríguez-Contreras Pelayo R, Gálvez Vargas R
Centro de Salud Zaidin-Sur, Facultad de Medicina, Granada.
Gac Sanit. 1991 Sep-Oct;5(26):214-8. doi: 10.1016/s0213-9111(91)71073-x.
The quality of the clinical records included in the clinical charts is assessed through a sample of the clinical charts existing at the Health Center Zaidin-Sur (Granada, Spain). The quality was ascertained via the number of visits annotated, the number of records considered as essential (life style, family and personal history), and the number of received or requested consultation. This information is compared to the data of the general files of the Health Center, to the information gathered by a direct interview (performed to assess the validity of the essential records), and to the results of a protocol studying the visit activities. The analysis of data shows that just a 40.4% of the visits are annotated on the clinical chart. A lower percentage of the essential records were annotated, 37.6%. The requested consultations are annotated in 43.8% and the received ones in 87.6%. We discuss on the need of periodic evaluation of the records to show their limitations and deficiencies. This is the first step to improve them.
通过对位于西班牙格拉纳达的扎伊丁健康中心现存临床图表的抽样，评估临床图表中包含的临床记录质量。通过标注的就诊次数、被视为基本记录（生活方式、家族和个人病史）的记录数量以及接收或请求的会诊数量来确定质量。将这些信息与健康中心总档案的数据、通过直接访谈收集的信息（用于评估基本记录的有效性）以及研究就诊活动的方案结果进行比较。数据分析表明，只有40.4%的就诊在临床图表上有标注。基本记录的标注比例更低，为37.6%。请求的会诊标注率为43.8%，接收的会诊标注率为87.6%。我们讨论了定期评估记录以显示其局限性和不足的必要性。这是改进记录的第一步。
