Analysis and Evolution of the Quality of the Clinical Histories in a Health Centre

Abstract

We present the results of three reviews of the degree of fulfilment of the clinical histories that annually and systematically have been carried out in the health centre. In the 1986 audit, 8 criteria were agreed upon, 11 in 1988 and 10 in 1989. It is to he highligted that only three of the criteria assessed (family folder, anamnesis and personal background) decreased the degree of fulfilment, with reductions of 15%, 8.5% and 0.6% respectively, between the first and tthe latest review. The remaining criteria increased, six of them with statiscally significant differences: individual folder (37% of 1989 registrations), pathology summary (56.4%), family background (38.4%), blood pressure (69.16%) analysis (66.9%) and Queteloc index (26.6%). We conclude the usefulness and need for the medical audit in Prirnary CTare teams as one of the ways of guaranteeing the quality of the information handled.