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  4. [Quality of the medical record notification in primary health care]

[Quality of the medical record notification in primary health care]

Authors

Asma Sriha Belguith
Sana, Elmhamdi
Ines, Bouanene
Meriem, Ben Saad
Aroua, Ben Salah
Chahida, Harizi
Mohamed, Soltani Essoussi
Tunisie Med. 2015; 93 (3): 148-152
Tunisie Medicale [La]
Journal Country: Tunisia
P-ISSN: 0041-4131
Type of Publication: Journal Article
Country of Research: Tunisia
Type of Research: Non Clinical
Keywords: Medical Records
Broad Subjects: Health Systems, Quality of Health Care ,Primary Health Care ,Retrospective Studies
Citation: Sriha Belguith Asma ,Elmhamdi Sana ,Bouanene Ines ,Ben Saad Meriem ,Ben Salah Aroua ,Harizi Chahida ,Soltani Essoussi Mohamed , [Quality of the medical record notification in primary health care], Tunisie Med. 2015; 93 (3): 148-152

Abstract English

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. 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] . 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%. 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] . The use of SMR improves the notification and the care continuity

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