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[Evaluation of the quality of inter-clinic documents. Does their proper filling out by the family doctor affect the reply obtained from the specialist?]

Authors :
B, Reig Mollá
E, Bisbal Andrés
J, Sanfélix Genovés
I, Pereiró Berenguer
M J, Esparza Pedrol
R M, Martín González
Source :
Aten Primaria
Publication Year :
2004

Abstract

OBJECTIVE: To analyse the filling out of the inter-clinic form (IF) at a centre with special fields of care (CS) and to assess whether its proper filling out in primary care (PC) affects the reply from specialist care DESIGN: Cross-sectional, descriptive study SETTING: Primary health care area in the Community of Valencia PARTICIPANTS: Randomised sample of IFs of patients referred for the first time from PC to specialists MAIN MEASUREMENTS: Evaluation criteria were grouped in two: those IFs were considered acceptable (IFCA) in which the family doctor included the reason for consultation or his/her diagnostic impression, as well at least one of the following: anamnesis, personal background, physical examination, further tests or current medication. The remaining IFs were considered inadequately filled out (IFCI) RESULTS: The sample analysed for the IF audit ofthe CS was 392 people. The result of the audit in the specialist clinics was that 243 IFs were blank (62.0%); the specialist doctor was identified in 19% of cases; the diagnosis was given in 23.5%; treatment, in 21%, and the follow-up plan, in 20%. In the PC evaluation, there were no blank IFs; anamnesis was recorded in 41.8%; reason for consultation in 73%; suspected diagnosis in 58.2%, and treatment in 11.5%. The sample to analyse the differences in the filling of the form in specialist care according to the quality of the PC filling out was 529 IFs. 56.3% of the IFs were considered acceptable. No statistically significant differences were found inthe filling of any of the criteria of evaluation by the specialist doctor between the IFs from PC of acceptable and inadequate quality, except on thequestion of specifying treatment CONCLUSIONS: We found no relationship between the quality of the IF from PC and the reply from specialist care. Currently, the filling out of IFs continues to be deficient

Details

ISSN :
02126567
Volume :
34
Issue :
6
Database :
OpenAIRE
Journal :
Atencion primaria
Accession number :
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