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[The benefits of auditing clinical histories. Our experience over 5 years]
1Departamento de Medicina, Universidad de Alicante.
Objective:
To evaluate how our clinical records (CR) are filled in and to observe the impact of measures taken to correct faults found over a five-year follow-up period.
Design:
Three descriptive studies (auditing methodologies) on representative samples of CR selected at random. Four quality indicators were fixed: internal communication (i.e. legibility and comprehensibility), external communication, manageability and the quality of the activity at attendances measured by the SOAP. The optimum standards (OS) were agreed by the team (technique of nominal group).
Setting:
"Florida" Health Centre, Alicante.
Patients And Others Participants:
Periodic team meetings to analyse results and agree activities. In 1986, N of CR = 367; in 1988, 370; and in 1990, 372.
Main Measurements And Results:
During the follow-up period, the filling-in of all the variables, except the address, the test carried out and blood pressure, improved. But the following did not reach the OS: code, affiliation, origin, instruction, habits, allergies, working activity, socio-economic data, age and gender, family/personal background, test carried out, blood pressure and analytical data. The following all reached the OS: legibility, which went up from 88% to 96.5%, comprehensibility from 62 to 75.3%, external communication from 81 to 88.9%, manageability from 53 to 79.6% and SOAP from 62 to 82.5%.
Conclusions:
Auditing allows the level of the filling-in of the CR to be measured. Deficiencies which appear to be due to the design of the record itself can be detected. The efficacy of corrective measures to improve records can also be assessed.