title: [Quality of the medical record notification in primary health care].
abstract: BACKGROUND
  The medical record is a very important tool for organizing, the planning and tracking of care. Her outfit is considered as one of the major criteria for care quality.
  
  
  OBJECTIVE
  compare, the degree of given collected notification on the Structured Medical Record (SMR) in Subjective, Pre-appreciation, Objective, Appreciation and Post-appreciation (SPOAP) and on Not Structured Medical Record (NSMR).
  
  
  METHODS
  It is a retrospective, analytic study, including 910 DM. Executed in four primary health centers, at Monastir governorate in 2010. As regards methodology, we conducted a sampling at 3 degrees. The first draw of the month, the second on the weeks, the third is systematic type of medical records with a step of sounding of 2. We collected information about patient's socio-demographic characteristics, the contact patterns, clinical examination of the data, assumptions and diagnostics procedures. We used chi2 test to compare the distribution between SMR and NSMR at the Threshold of 5 %.
  
  
  RESULTS
  Four hundred and one SMR (44 %) and 509 (56 %) NSMR were included. The contact patterns was noted on 44 % of NSMR and 93% of SMR (< 10-4). The physical examination had been noted on 67 % of SMR and 8% of NSMR (p < 10-4), the hypotheses diagnoses on 72 % of SMR and 31 % of NSMR (p < 10-4). The conducts had been noted on 98 % of SMR and 95% of NSMR (p < 0,045). The distribution of the motives for contacts, physical acts, hypotheses diagnoses and therapeutic families were different between SMR and NSMR. The medical records was adequate in 52 % of SMR and in 2% of NSMR (p < 10-4).
  
  
  CONCLUSIONS
  The use of SMR improves the notification and the care continuity.
authors.forename: Asma
authors.initials: A
authors.lastname: Sriha Belguith
authors.forename: Sana
authors.initials: S
authors.lastname: Elmhamdi
authors.forename: Inès
authors.initials: I
authors.lastname: Bouanene
authors.forename: M
authors.initials: M
authors.lastname: Ben Saad
authors.forename: Aroua
authors.initials: A
authors.lastname: Ben Salah
authors.forename: Chahida
authors.initials: C
authors.lastname: Harizi
authors.forename: Mohamed
authors.initials: M
authors.lastname: Soltani Essoussi
mesh_terms: D004282:Documentation; D006801:Humans; D008499:Medical Records; D011320:Primary Health Care; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D014416:Tunisia