[An intervention program to improve the quality of the medical records in an Internal Medicine Department]. / Intervención para la mejora de la calidad de las historias clínicas en un Servicio de Medicina Interna.

INTRODUCTION: 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. MATERIAL AND 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.

Intervención para la mejora de la calidad de las historias clínicas en un Servicio de Medicina Interna / An intervention program to improve the quality of the medical records in an Internal Medicine Department

Introducción: Las historias clínicas son documentos clave en el diagnóstico, tratamiento y seguimiento de los pacientes. Por ello es necesario realizar historias clínicas de elevada calidad técnica. Aunque hay estudios que relacionan la calidad de la historia clínica con un mejor control de una determinada enfermedad, conocemos pocos que evalúen la calidad intrínseca de las historias. El objetivo de este trabajo fue analizar la calidad de las historias clínicas de nuestro Servicio de Medicina Interna y, tras intervenir, valorar la mejoría conseguida. Material y métodos: Estudio de intervención antes/después que incluyó 186 historias clínicas elaboradas por los médicos de nuestro Servicio de Medicina Interna. Se diseñó una plantilla para evaluar 16 contenidos de ellas mediante una escala tipo Likert. Se analizaron las variables ítem por ítem y con un score combinándolos. Se realizó un análisis basal y otro tres meses después, tras realizar varias intervenciones. Resultados: Se detectaron las insuficiencias de las historias al inicio (que se describen) y tras las intervenciones. Con ellas se obtuvo mejoría en prácticamente todos los ítems seleccionados, destacando la mejor cumplimentación de las alergias y los hábitos vitales. El score global mejoró también de manera significativa. Conclusión: El estudio nos ha permitido conocer nuestras insuficiencias en la elaboración de las historias clínicas. Con las intervenciones hemos aumentado su calidad. Estimamos que esta actuación ha resultado formativa para los médicos de plantilla, residentes y estudiantes de nuestro Servicio, y creemos que ha mejorado la calidad de nuestras actuaciones (AU)

Introduction: 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. Material and 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 (AU)