Huertas Zarco I, Pereiró Berenguer I, Sanfélix Genovés J, Rodríguez Moya R
Unidad de Investigación-Programas, Dirección de Atención Primaria Areas 3 y 4, Valencia.
Aten Primaria. 1996 Mar 31;17(5):317-20.
To quantify the improvement in compliance with filling out the interclinical note after both general practitioners and specialists were informed of the compliance level found in an earlier study.
An intervention before-and-after study. Unit of analysis: interclinical note in the primary care clinical record.
Health Areas 11 and 12 in the Community of Valencia, November 1993 and 1994. Field work was developed on the premises of the two specialist centres of these areas.
Two samples, of 708 and 326 interclinical notes, were used. These were stratified in function of the number of consultations during the first six months of each of the study years, by centre and speciality.
All primary care and specialist professionals were informed of the level of compliance with the interclinical note in the first part of the study.
The primary care section improved significantly in: personal history, data on physical examination, suspected diagnosis, reason for consultation. The section on specialists improved significantly in the identification of the specialist, diagnosis, treatment, action to take.
Information given to professionals improved their filling out of the interclinical note, basically on variables to do with the pathological process. It should be routine to feed back information to the professionals concerned.
在向全科医生和专科医生通报早期研究中发现的填写临床间记录的依从性水平后，量化依从性的改善情况。
一项干预前后研究。分析单位：初级保健临床记录中的临床间记录。
1993年11月和1994年，巴伦西亚自治区第11和12健康区。实地工作在这些地区的两个专科中心进行。
使用了两个样本，分别为708份和326份临床间记录。这些样本根据每个研究年度前六个月的会诊次数、中心和专业进行分层。
在研究的第一部分，向所有初级保健和专科专业人员通报了临床间记录的依从性水平。
初级保健部分在以下方面有显著改善：个人病史、体格检查数据、疑似诊断、会诊原因。专科部分在专科医生的识别、诊断、治疗、采取的行动方面有显著改善。
向专业人员提供的信息改善了他们填写临床间记录的情况，主要是在与病理过程相关的变量方面。向相关专业人员反馈信息应成为常规做法。
