A comparative analysis of 11 adult case histories used in primary care
Rubio Villegas, C.; Corrales Nevado, D.
Atencion Primaria 11(1): 16-17; 19-20
1993
ISSN/ISBN: 0212-6567 PMID: 8427912 Document Number: 417481
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. A descriptive study. Eleven individual adult PC cases histories, still open in 1991. 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. 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.