Gil V, Arenas M, Quirce F, Orozco D, Belda J, Merino J
Departamento de Medicina, Universidad de Alicante.
Aten Primaria. 1994 Mar 15;13(4):182-6.
We aimed to discover the opinion of primary care doctors regarding the structure, usefulness and problems when using two models of clinical records employed consecutively in the same health centres.
A double crossover study. An opinion poll (with 22 closed questions and one open), filled out in 1988 (evaluating the type A clinical record) and then in 1992 (for type B), was used. Chi squared statistical analysis with Yates corrections and Fisher test.
Staff doctors and third-year family and community medicine interns at their teaching centres in Alicante province. In 1988, 49 doctors took part, and in 1992, 68: 70 and 75% respectively of the target group.
The new record was an improvement over the earlier one. It was broader and corresponded more closely to the actual case. But problems of completion and legibility persisted, as did the difficulties in filling out socio-economic data and work/school history. Model B favoured use by all the team members. It was better for new patients and when doing later checks, although it did not avoid the accumulation of inactive documentation. The need for specific documents for preventive activities was detected. Computerisation would improve manageability. For both models lack of time was the main reason for under-recording.
The new model is better than the earlier one but is lacking in the areas of manageability and difficulty in retrieving information. The methodology employed shows its use for evaluating health-care innovations and detecting insufficiencies, as well as allowing user-satisfaction to be more easily identified.
