[Evaluation of alcohol consumption recording in the primary care clinical history].
We carried out an internal medical audit to evaluate the recording of alcohol use in the primary care clinical records. 200 records were analyzed out of overall 2250. Of these, 100 belonged to the open (older) model, and 100 to the closed (or current) one. We found that in 56% of open model records there was no mention about alcohol use, against 31% in closed model records. In addition, this latter model permits a quantitative recording of alcohol intake. In both models there was a greater amount of information in males. We conclude that the physician's interest in recording data related to alcohol intake is small. We think that primary care staff should be sensitized to the importance of evaluating and recording alcohol intake.
Aubà Llambrich
J F
JF
Fandos Olona
J M
JM
Hernández Alonso
A R
AR
Fores García
M D
MD
D000328:Adult; D000368:Aged; D000428:Alcohol Drinking; D005260:Female; D006801:Humans; D008297:Male; D008485:Medical Audit; D008499:Medical Records; D008875:Middle Aged; D011320:Primary Health Care; D013030:Spain
Valoración del registro de consumo de alcohol en la historia clínica de atención primaria.