Quality of the medical record notification in primary health care

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Published Jul 22, 2015
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Vol. 93 No. 3 (2015): Issue Mar 2015

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Sriha Belguith Asma
Elmhamdi Sana
Bouanene Inès
Ben Salah Aroua
Aroua Harizi Chahida
Soltani Essoussi Mohamed

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.
Aim: 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). Conclusion: The use of SMR improves the notification and the care continuity

Keywords:

Medical records; primary health care, International Classification of Primary Care

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