Rodríguez-Contreras R, López Gigosos R M, Aguado Mingorance A, Gastón Morata J L, Bueno Cavanillas A, Lardelli Claret P, Gálvez Vargas R
Universidad de Granada, Facultad de Medicina, Departamento de Medicina Preventiva, España.
Bol Oficina Sanit Panam. 1993 Mar;114(3):242-7.
The objective of this study was to assess the quality of the data included in patients' personal histories and to prepare an indicator of the continuity of health care between episodes of illness based on the information contained in these records. The study was descriptive. Public health specialists from the Department of Preventive Medicine of the University of Granada, Spain, participated in the design and analysis, and the field work was carried out by specialists from family and community medicine from the Zaidín-Sur Health Center of Granada, where the research was conducted in April to December 1989. For the study, 1581 personal histories were analyzed. The most complete records were those having to do with personal background (37% of the personal histories evaluated) and the most complete histories were those of pediatric patients, women, and persons who participated in programs organized by the health center. The degree of completeness of the records was low. Based on the indicator developed, only 16% of the histories at the Center contained sufficient information to allow continuity of care. It is recommended that simple records systems be created and that primary care physicians be educated in the collection of essential data.
本研究的目的是评估患者个人病史中所包含数据的质量，并根据这些记录中的信息制定一个疾病发作期间医疗保健连续性的指标。该研究为描述性研究。西班牙格拉纳达大学预防医学系的公共卫生专家参与了设计与分析，实地工作由格拉纳达Zaidín-Sur健康中心的家庭与社区医学专家开展，研究于1989年4月至12月在该中心进行。本研究分析了1581份个人病史。最完整的记录是与个人背景相关的记录（占所评估个人病史的37%），而最完整的病史是儿科患者、女性以及参与健康中心组织项目的人员的病史。记录的完整程度较低。根据所制定的指标，该中心只有16%的病史包含足够信息以确保医疗保健的连续性。建议创建简单的记录系统，并对初级保健医生进行基本数据收集方面的培训。
