Corral Gómez F J, Arrojo López I, Gallego Valdeiglesias A, Martínez Barredo J M, Meilán Pérez A, Míguez Gallego M, Machín Fernández A J
EAP Sagrado Corazón, Lugo.
Aten Primaria. 1993 Sep 15;12(4):220-2.
To assess how fully clinical records (CR) at a health centre are filled in, using quality control techniques.
Retrospective, descriptive study. SITE. The "Sagrado Corazón" (Lugo) Health team, made up of 6 General practitioners, 7 nursing staff (ATS-DUE) and 1 paediatrician.
A systematic sample of 400 adult CR.
The data card and follow-up sections were correct in over 90% of CR. Weight and height were correct in 25.75%. The composite indicator showed that 32.25% of CR were correct. Results were better for CR of users over 44. The differences were significant for: personal case histories, Arterial Pressure, allergies, weight and height and composite indicator.
The lack and bad distribution of nursing offices and weighing-scales could explain the results of the height and weight sections. The CR is not just a document store. However it must be improved.
运用质量控制技术评估健康中心临床记录（CR）的填写完整程度。
回顾性描述性研究。地点：由6名全科医生、7名护理人员（助理护士-二级护士）和1名儿科医生组成的“圣心”（卢戈）健康团队。
400份成人临床记录的系统样本。
超过90%的临床记录中数据卡和随访部分正确。体重和身高记录正确的占25.75%。综合指标显示32.25%的临床记录正确。44岁以上使用者的临床记录结果更好。在个人病史、血压、过敏、体重和身高以及综合指标方面差异显著。
护理办公室和体重秤的短缺及分布不佳可能解释身高和体重部分的结果。临床记录不仅仅是文件存储。然而必须加以改进。
