[Quality of medical records at a primary care center]

The quality of the clinical records included in the clinical charts is assessed through a sample of the clinical charts existing at the Health Center Zaidin-Sur (Granada, Spain). The quality was ascertained via the number of visits annotated, the number of records considered as essential (life style, family and personal history), and the number of received or requested consultation. This information is compared to the data of the general files of the Health Center, to the information gathered by a direct interview (performed to assess the validity of the essential records), and to the results of a protocol studying the visit activities. The analysis of data shows that just a 40.4% of the visits are annotated on the clinical chart. A lower percentage of the essential records were annotated, 37.6%. The requested consultations are annotated in 43.8% and the received ones in 87.6%. We discuss on the need of periodic evaluation of the records to show their limitations and deficiencies. This is the first step to improve them.