[The auditing of the clinical histories of a health center].

OBJECTIVE

To assess how fully clinical records (CR) at a health centre are filled in, using quality control techniques.

DESIGN

Retrospective, descriptive study. SITE. The "Sagrado Corazón" (Lugo) Health team, made up of 6 General practitioners, 7 nursing staff (ATS-DUE) and 1 paediatrician.

PATIENTS AND OTHER PARTICIPANTS

A systematic sample of 400 adult CR.

MAIN MEASUREMENTS AND RESULTS

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.

CONCLUSIONS

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.