RESUMO
OBJECTIVES: To quantify with primary data the various kinds of consultations, the reasons for them and the diagnoses; to measure preventive actions and diagnoses using machines. To check the recording of the kinds of consultations and reasons for them in the clinical notes and on the doctor's work-sheet. DESIGN: Observation, cross-sectional and multi-centre study. Clinical care activity was measured on two January days in 2002. SETTING: All the health centres in Area 17 of the Community of Valencia. PARTICIPANTS: Representative sample of 2051 patients belonging to 20 primary care medical clinics from the above area, selected by sampling stratified by health centres. MAIN MEASUREMENTS: The activity of a working day was recorded and structured as follows: a) care activity (scheduling, age, sex, records code, kind of consultation and motive, specifying whether this was care activity, preventive or bureaucratic); b) activity caused by main reason for consultation (anamnesis, examination and further tests); c) plan of action (hygienic and dietary measures, medication and referrals); d) use of the clinical records according to SOAP sections; e) interruptions during the consultation. RESULTS: Study of care activity and its correlation with the actions recorded in the clinical record with primary data enables the reality of health care to be fairly faithfully perceived. These results highlighted the usefulness of clinical record audits to measure health-care delivery and to identify patterns of consumption of health resources, as a necessary pre-condition of more efficient primary care management.
