A clinical record assessment in a private health facility in Ocotepeque, Honduras

Abstract

Introduction. A proper filling of the clinical record is key to quality medical care. The study aim was to evaluate the filling of the clinical record in an ambulatory medical care center in the private sector of the department of Ocotepeque, Honduras from January 2020 to June 2022. Methods. The study was quantitative, non-experimental, and a cross-sectional descriptive study. The universe included 3,904 physical clinical records. Data was collected from a probabilistic sample of 350 cases using a self-made instrument. Results. 87.9% of the health attentions had a partial or deficient record (95% CI: 85.1 to 90.7%). Regarding patient identification and temporality in the medical attentions, in 98.9% the complete date, in 29.7% the time of attention with a doctor and in 85.0% the full name of the patient was recorded. For the medical care process, it was found that in 48.9% the name of the responsible physician, in 64.2% the complete vital signs, and in 89.2% the clinical diagnosis was recorded. Conclusion. The filling of the clinical record of the health care provided in the establishment under study was deficient, which disables the numerous benefits that it grants to the patient, health personnel and management, including the quality of the medical care.