[Evaluation and improvement of the design of clinical records]. 1994

J Saura Llamas, and P J Saturno Hernández
Centro de Salud Universitario del Barrio del Carmen, Murcia.

OBJECTIVE To determine whether applying the methodology of Evaluation and care quality improvement to the design of Clinical Procedures can obtain Procedure documents of high scientific-technical quality, from the structural point of view. METHODS A retrospective evaluation study lasting 3 years. METHODS The Barrio del Carmen Health Centre in Murcia. METHODS The Primary Care team. All those professionals with activities involving Procedure documents. METHODS The object of study is all the documentation of the Procedures produced between 1985 and 1993. The initial evaluation was in 1990. After the detection of deficiencies, corrective measures were proposed. In 1993 there was a re-evaluation, using the compliance scales of the quality of design criteria, which had been previously worked out on the basis both of the most important parts of the Bibliography and the quality specifications stated by the system's internal clients (the professionals). Measurements were made before and after intervention. RESULTS After the application of the corrective measures arising from the first evaluation, a significant improvement in all the design criteria for the procedures was obtained: the average defects per procedure document fell from 8.26 to 1.85. Three of the procedure documents ended up having no defects, either in structure or formal design (format, design method and document production). CONCLUSIONS A substantial improvement in the structural quality of the documents for the Procedures developed in our Health Centre was achieved by applying the methodology of evaluation and quality improvement.

UI MeSH Term Description Entries
D008499 Medical Records Recording of pertinent information concerning patient's illness or illnesses. Health Diaries,Medical Transcription,Records, Medical,Transcription, Medical,Diaries, Health,Diary, Health,Health Diary,Medical Record,Medical Transcriptions,Record, Medical,Transcriptions, Medical
D005069 Evaluation Studies as Topic Works about studies that determine the effectiveness or value of processes, personnel, and equipment, or the material on conducting such studies. Critique,Evaluation Indexes,Evaluation Methodology,Evaluation Report,Evaluation Research,Methodology, Evaluation,Pre-Post Tests,Qualitative Evaluation,Quantitative Evaluation,Theoretical Effectiveness,Use-Effectiveness,Critiques,Effectiveness, Theoretical,Evaluation Methodologies,Evaluation Reports,Evaluation, Qualitative,Evaluation, Quantitative,Evaluations, Qualitative,Evaluations, Quantitative,Indexes, Evaluation,Methodologies, Evaluation,Pre Post Tests,Pre-Post Test,Qualitative Evaluations,Quantitative Evaluations,Report, Evaluation,Reports, Evaluation,Research, Evaluation,Test, Pre-Post,Tests, Pre-Post,Use Effectiveness
D000465 Algorithms A procedure consisting of a sequence of algebraic formulas and/or logical steps to calculate or determine a given task. Algorithm
D012189 Retrospective Studies Studies used to test etiologic hypotheses in which inferences about an exposure to putative causal factors are derived from data relating to characteristics of persons under study or to events or experiences in their past. The essential feature is that some of the persons under study have the disease or outcome of interest and their characteristics are compared with those of unaffected persons. Retrospective Study,Studies, Retrospective,Study, Retrospective
D013030 Spain Country located between France on the northeast and Portugal on the west and bordered by the Atlantic Ocean and the Mediterranean Sea. The capital is Madrid. Balearic Islands,Canary Islands
D016347 Medical Records Systems, Computerized Computer-based systems for input, storage, display, retrieval, and printing of information contained in a patient's medical record. Automated Medical Records Systems,Computerized Medical Records Systems,Automated Medical Record System,Automated Medical Record Systems,Automated Medical Records System,Computerized Medical Record System,Computerized Medical Record Systems,Computerized Medical Records System,Computerized Patient Medical Records,Medical Record System, Automated,Medical Record System, Computerized,Medical Record Systems, Automated,Medical Record Systems, Computerized,Medical Records System, Automated,Medical Records System, Computerized,Medical Records Systems, Automated

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