Objectives. To examine how well the clinical process was recorded in the clinical history (CH), and care delivery on the activity sheet (AS). To assemble a series of recommendations on the validity of these documents for recording health care delivery. Design. Multi-centred, observational, and cross-sectonal study. Setting. Four medical clinics at 12 health centres in the Community of Valencia, Spain. Participants. There were 2051 attendances, with 284 CH and 407 AS involved. Main measurements and results. The information recorded by doctors in the CH and on the AS was validated by external observers who collected directly at the consultation the working day's entire care activity. The following was analysed: 1) in the CH, filling out of the "SOAP" form (basic info.); 2) on the AS, mean per professional per day of scheduled and on-demand patients, home visits and length of consultations; 3) information in the documents validated on the organisation of consultations; 4) analysis of care delivery according to how predictable it is and its clinical content; 5) clinical practice guidelines with validity and clinical usefulness indicators and reliability index (kappa). Conclusions. The documents validated do not properly reflect the reality of health care demand. There was an under-recording bias and validity problems that may limit their usefulness as sources of information for health care planning and management.
Pedrera-Carbonell, V., Gil-Guillén, V., Orozco-Beltrán, D., Prieto Erades, I., Schwarz-Chavarri, G., & Moya-García, M. I. (2005). Validez de la historia clínica y sistemas de información en los estudios de actividad asistencial en atención primaria. Atencion Primaria, 36(10), 550–557. https://doi.org/10.1016/s0212-6567(05)70565-5