[The auditing of the clinical histories of a health center].
OBJECTIVE
To assess how fully clinical records (CR) at a health centre are filled in, using quality control techniques.


METHODS
Retrospective, descriptive study. SITE. The "Sagrado Corazón" (Lugo) Health team, made up of 6 General practitioners, 7 nursing staff (ATS-DUE) and 1 paediatrician.


METHODS
A systematic sample of 400 adult CR.


RESULTS
The data card and follow-up sections were correct in over 90% of CR. Weight and height were correct in 25.75%. The composite indicator showed that 32.25% of CR were correct. Results were better for CR of users over 44. The differences were significant for: personal case histories, Arterial Pressure, allergies, weight and height and composite indicator.


CONCLUSIONS
The lack and bad distribution of nursing offices and weighing-scales could explain the results of the height and weight sections. The CR is not just a document store. However it must be improved.
EAP Sagrado Corazón, Lugo.
F J
FJ
Corral Gómez
I
I
Arrojo López
A
A
Gallego Valdeiglesias
J M
JM
Martínez Barredo
A
A
Meilán Pérez
M
M
Míguez Gallego
A J
AJ
Machín Fernández
D003151:Community Health Centers / Q000706:statistics & numerical data; D016001:Confidence Intervals; D005069:Evaluation Studies as Topic; D006801:Humans; D008485:Medical Audit / Q000706:statistics & numerical data; D008499:Medical Records / Q000592:standards / Q000706:statistics & numerical data; D011786:Quality Control; D011787:Quality of Health Care / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013030:Spain