[An intervention program to improve the quality of the medical records in an Internal Medicine Department].
BACKGROUND
The medical records are key documents for the patient's diagnosis, treatment and follow-up. Thus, the clinical histories must be made with high technical quality. Although some studies relate the quality of the clinical history with better control of a disease, as far as we know, there are few that evaluate the quality of the medical record itself. This study aims to analyze the quality of the clinical histories of our Internal Medicine Department and then evaluate the improvement achieved.


METHODS
A descriptive and intervention study with a before and after design was conducted. It included 186 medical records elaborated by the physicians of our Internal Medicine Department. A 16-item Likert-like scale was designed for the evaluation. The items were analyzed item by item and a score combining them was elaborated. A baseline analysis and a second analysis 3 months after making several interventions were made.


RESULTS
Weak points were detected in the baseline analysis (described) and after the interventions. There was an improvement in almost all the items, this being very significant in the recording of allergies and habits. The global score also improved significantly. CONCLUSION. The study has allowed us to learn our weak points in the elaboration of the medical records. We have improved their quality with the interventions. We estimate that this intervention has also been useful for the training of internal medicine physicians, residents and students.
Servicio de Medicina Interna, Hospital Universitario de San Juan, Alicante, España.
A
A
Wikman
P
P
Safont
J
J
Merino
A
A
Martínez Baltanás
M
M
Matarranz Del Amo
E
E
López Calleja
D006748:Hospital Departments; D007388:Internal Medicine; D008499:Medical Records / Q000592:standards*; D011786:Quality Control; D011795:Surveys and Questionnaires