Assuntos
Protocolos Clínicos , Prontuários Médicos , Atenção Primária à Saúde/organização & administração , Estudos de Avaliação como Assunto , Seguimentos , Controle de Formulários e Registros/estatística & dados numéricos , Humanos , Prontuários Médicos/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , EspanhaRESUMO
OBJECTIVE: A comparative analysis of the different models of adult case history at primary care (PC) level available in the Spanish state. Their degree of homogeneity, both in design and information-gathering capacity, was evaluated. DESIGN: A descriptive study. MATERIAL: Eleven individual adult PC cases histories, still open in 1991. MAIN MEASUREMENTS AND RESULTS: Only four of the models allowed more than 75% of the basic data to be gathered. Three histories had up to six loose pages. In six, the presence of specific records was verified. CONCLUSIONS: There is a lack of standardisation both in the designs of case histories and in the information which these allow to be gathered. Information was scattered because of the presence of specific records and of loose pages. Systematic inclusion of preventive activities into the records is not sufficiently normalised.
