Concordancia y calidad de las historias clínicas en los alumnos de Medicina: ¿reflejan la realidad de la consulta?

Abstract

Introduction

Writing medical histories (MH) is a basic competence in the physician's training. It is the cornerstone for constructing diagnostic hypotheses and guaranteeing adequate, safe and effective care. In addition, MH has legal, epidemiological and quality of care implications. The aim of this study was to determine the concordance between the information collected from the patient in the consultation room and that recorded in the MH by medical students.

Methods

This is a cross-sectional descriptive observational study on a consultation with simulated patients and the subsequently written MH. A total of 112 5th-year medical students participated. The evaluators checked 59 items of anamnesis, anamnesis by organs and apparatus, physical examination and clinical judgment in the MH, contrasting them with the video recordings of the consultations, and classifying the concordance between both.

Results

Final population was 109 students (97.3%). The competency area with the highest concordance was clinical judgment (94.1%). All items exceeded 65% agreement. More than 20% of the students had not recorded some items in their MH, although they had collected them in the consultation. Anamnesis by organs and apparatus was the competency area with the most omitted or incorrect items. The only item that no student forgot to collect and record was “personal history of dyslipidemia”. Physical examination was the area where most students recorded findings in the MH without having made them in the interview.

Conclusion

The study demonstrates high concordance in the MH with the information collected in the consultation and shows aspects that will allow us to improve the medical semiology training of students.