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[The auditing of the clinical histories of a health center].

OBJECTIVE
To assess how fully clinical records (CR) at a health centre are filled in, using quality control techniques.


DESIGN
Retrospective, descriptive study. SITE. The "Sagrado Corazón" (Lugo) Health team, made up of 6 General practitioners, 7 nursing staff (ATS-DUE) and 1 paediatrician.


PATIENTS AND OTHER PARTICIPANTS
A systematic sample of 400 adult CR.


MAIN MEASUREMENTS AND RESULTS
The data card and follow-up sections were correct in over 90% of CR. Weight and height were correct in 25.75%. The composite indicator showed that 32.25% of CR were correct. Results were better for CR of users over 44. The differences were significant for: personal case histories, Arterial Pressure, allergies, weight and height and composite indicator.


CONCLUSIONS
The lack and bad distribution of nursing offices and weighing-scales could explain the results of the height and weight sections. The CR is not just a document store. However it must be improved.