Historia clínica de atención primaria: calidad y factores asociados

Abstract

To obtain a method which allows quantitative evaluation of the register of risk factors in the primary care medical records of the adult population and to analyze the effect that several factors, related to primary care centers, users and physicians in primary care, determine over it. An observational cross-sectional study. Primary health care. A total sample of 1473 medical records from eight health districts of Catalonia. Information was collected using a structured questionnaire, with socio-demographic data related to the primary care center, the users and the primary care physician, which also collected criteria of the risk factors of the medical records defined a priori by a consensus group of professionals in primary health care. Only 18.3% (95% CI: 16.3-20.3%) of the total medical records sample analyzed accomplished criteria of minimum data set register. Risk was higher due: a higher number of physicians in the Primary care centers (OR = 1.10; 95% CI: 1.01-1.20); female gender of the user (OR = 1.17; 95% CI: 1.01-1.36); older age of the user (OR = 1.02; 95% CI: 1.02-1.03); if there was one visit during last year at least (OR = 1.51; 95% CI: 1.23-1.85); and female gender of the physician who fulfilled the Medical Record (OR = 1.46; 95% CI: 1.24-1.71). Average of minimum data set register of the medical record of the adult population is 18.3% (95% CI: 16.3-20.3). The following factors are related to minimum data set register: more number of physicians in the primary care center, female sex of the user, year of last register in medical record, and female sex of the physician.