Clinical data that are essential for the primary care clinical records: an experience of evaluation and improvement

• Published in: Atención primaria Vol. 30; no. 2; pp. 92 - 98
• Main Authors: López-Picazo Ferrer, J J, Agulló Roca, F, Villaescusa Pedemonte, M, Cerezo Corbalán, J M
• Format: Journal Article
• Language: Spanish
• Published: Spain 30.06.2002
• Subjects: Humans; Medical Audit - methods; Medical Records - standards; Primary Health Care - standards; Quality Assurance, Health Care - methods; Sampling Studies; Spain; Spain
• ISSN: 0212-6567

To evaluate and improve the presence of essential clinical data in the clinical records of a primary care management area (PCMA) by means of an intervention programme. Intervention study without a control, using evaluation and improvement-of-quality methods. We chose 4 criteria from the minimum technical standards: personal history (PH), family background (FB), allergies to medicines (AM) and list of problems (LP). We evaluated overall compliance and compliance per primary care team (PCT) through batch quality acceptance of samples (LQAS), designed an intervention to improve the situation, and then re-evaluated. PCMA of Murcia (45 PCTs). Participants. 42 PCTs (3 were excluded because they had poor coverage in their records). These lasted 12 months (October 1999-October 2000) and involved the following: graphic report per PCT; session with the PCT; discussion on results and strategies in the Area Management Council; and inclusion of an explicit objective, with incentives, in the management contracts. Significant improvement of the four criteria of the PCMA (improvements: FB, 48.1%; PH, 51.1%; AM, 55.4%; LP, 50.9%). LQAS analysis: we rejected 24 batches (14.3%) at the 1st evaluation and 15 (9.0%) at the second, with FB being the criterion most rejected in both instances. Defects appeared in 14 PCT (33.3%; 3 PCT accounted for 41.7%) at the 1st evaluation, and 7 PCT at the re-evaluation (16.7%; 2 reaching 46.7%). The presence of essential clinical data in clinical records has improved. LQAS proved to be a rapid and simple method for evaluating, improving and monitoring quality in primary care.