[Clinical records: our experience during the 1st year].

OBJECTIVE

To describe the evolution of attendance indicators over a period of a year on introducing a new model of health care.

DESIGN

Observational and descriptive.

SETTING

A local primary health care consulting-room.

PARTICIPANTS

Population in the census, population requesting care, population with medical records, the number of visits and reasons for attendance.

INTERVENTION

The introduction of clinical records, medical and nursing consultations by appointment, long-treatment booklets and a basic recording system.

MAIN RESULTS

54% of the population was recorded. Morbidity indicators, the first and subsequent visits and the number of prescriptions per patient were all stable. The percentage of bureaucratic reasons for attendance went down and the proportion of scheduled attendances increased. Requests for complementary tests and referrals to specialists also increased.

CONCLUSIONS

The greatest effort in opening clinical records took place during the first four months. The most telling indicators of the evolution of attendances are the percentages of bureaucratic visits and scheduled ones, the requests for complementary tests and referrals to specialists. Other common attendance indicators have contributed no additional information, yet have supposed a greater effort of data-gathering.