Valoración del uso de las historias clínicas en consulta a demanda de atención primaria

Objetivos

: Valorar el uso de las historias clínicas (HC), así como la calidad del registro diario (uso de SOAP, S: datos subjetivos; O: exploración; A: diagnóstico, y P: planes) en la consulta a demanda en primeras y segundas visitas.

Metodos

: Diseño descriptivo, retrospectivo, observacional, en un centro de salud rural-urbano. Revisión interna en HC de un muestreo aleatorio de visitas a demanda de 5 médicos, estratificadas por tipo de visita y médico (117 primeras y 117 segundas de cada médico para α = 0,05, β = 0,1, diferencia a detectar 20% y uso estimado del 75%), desde septiembre de 1994 a agosto de 1995. Se midieron las variables: sexo, edad, presión asistencial, número de citados con HC, día de la semana, jornada (mañana/tarde), presencia de anotación, legibilidad, quién anota (médico titular/otro facultativo), tipo de encuentro (directo/indirecto), uso de SOAP (SOAP mínimo: anotación de S o A y P; SOAP completo: en primeras anotación completa, en segundas registro de S, O y P).

Resultados

: El uso de HC es del 71,2% ± 2,7 (IC del 95%), con diferencias entre médicos p < 0,0001 (desde 93,6% ± 2,8 a 40,3% ± 6,2). El SOAP completo aparece en el 32,5% ± 3,2 de las anotaciones y el SOAP mínimo en el 87,1% ± 2,3, con diferencias entre médicos (p < 0,0001). Si anota el facultativo habitual, el SOAP completo es del 30,7 ± 3,4% y del 48,2% ± 3,6 si anota otro (p < 0,001).

Conclusiones

: El uso de la HC en la consulta a demanda está condicionado, sobre todo, por el facultativo que atiende, no influyendo el resto de variables estudiadas. Hay mejor anotación completa cuando el que anota no es el facultativo habitual.

Objectives

: To evaluate the use of medical records and the quality of the daily register (use of SOAP notes. S: Subjective, O: Objective, A: Assessment, P: Plan) in first and second patient visits on demand.

Methods

: Observational retrospective descriptive study design carried out in a rural-urban health center. An internal review was made of the medical records corresponding to a random sample of the appointments on demand of 5 physicians. Appointments were stratified by type and physician (117 first appointments and 117 second appointments for each physician; α = 0.05, β = 0.1; difference to detect 20% and estimated use 75%) and took place from September 1994 to August 1995. The following variables were measured: sex, age, appointment pressure, number of patients cited who had medical records, day of the week, workshift (morning/afternoon), presence of notes, legibility, person taking the history (physician/ other), type of encounter (direct/indirect), SOAP use (minimum SOAP: either S or A, and P; complete SOAP: a complete record in the first visit, S and O and P in the second visit).

Results

: The medical history was used in 71.2% ± 2.7 (95% CI), and use of records differed significantly between physicians p < 0.0001 (range: 93.6% ± 2.8 to 40.3% ± 6.2). Complete SOAP was obtained in 32.5% ± 3.2 of the notes and minimum SOAP in 87.1%± 2.3, with significant differences between physicians. If the regular physician completed the history, complete SOAP was present in 30.7% ± 3.4 compared with 48.1% ± 3.6 if another physician completed the history (p < 0.01).

Conclusions

: The use of the medical history in appointments on demand is conditioned, above all, by the attending physician. Other variables had little influence. The record was more complete when the person taking the history was not the patient' s regular physician.