[Validity of clinical records and information systems in studies of health-care delivery in primary care].
OBJECTIVE
To examine how well the clinical process was recorded in the clinical history (CH), and care delivery on the activity sheet (AS). To assemble a series of recommendations on the validity of these documents for recording health care delivery.


METHODS
Multi-centred, observational, and cross-sectonal study.


METHODS
Four medical clinics at 12 health centres in the Community of Valencia, Spain.


METHODS
There were 2051 attendances, with 284 CH and 407 AS involved. Main measurements and results. The information recorded by doctors in the CH and on the AS was validated by external observers who collected directly at the consultation the working day's entire care activity. The following was analysed: 1) in the CH, filling out of the "SOAP" form (basic info.); 2) on the AS, mean per professional per day of scheduled and on-demand patients, home visits and length of consultations; 3) information in the documents validated on the organisation of consultations; 4) analysis of care delivery according to how predictable it is and its clinical content; 5) clinical practice guidelines with validity and clinical usefulness indicators and reliability index (kappa).


CONCLUSIONS
The documents validated do not properly reflect the reality of health care demand. There was an under-recording bias and validity problems that may limit their usefulness as sources of information for health care planning and management.
Pedrera-Carbonell
V
V
Unidad de Investigación y Docencia del Area 17 (Conselleria de Sanitat, Generalitat Valenciana), Las Acacias, Elda, Alicante, Spain. pedrera_vic@gva.es
Gil-Guillén
V
V
Orozco-Beltrán
D
D
Prieto Erades
I
I
Schwarz-Chavarri
G
G
Moya-García
Mi
M
D003430:Cross-Sectional Studies; D006751:Hospital Information Systems / Q000592:standards*; D006801:Humans; D008499:Medical Records / Q000592:standards*; D011320:Primary Health Care; D013030:Spain