Concordancia y calidad de las historias clínicas en los alumnos de Medicina: ¿reflejan la realidad de la consulta?.
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2024
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Educación Médica
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Abstract
Introducción: la redacción de historias clínicas (HC) es una competencia básica en la formación
del médico. Es el fundamento para construir hipótesis diagnósticas y garantizar una atención
adecuada, segura y efectiva. Además, la HC tiene implicaciones legales, epidemiológicas y de
calidad asistencial. Con este estudio pretendimos conocer la concordancia entre la información
recogida del paciente en la consulta y la registrada en la HC por alumnos de Medicina.
Métodos: estudio observacional descriptivo transversal sobre una consulta con pacientes
simulados y la HC redactada posteriormente. Participaron 112 alumnos de 5.° año de Medicina.
Los evaluadores comprobaron en las HC 59 ítems de anamnesis, anamnesis por órganos y
aparatos, exploración física y juicio clínico, contrastándolos con las videograbaciones de las
consultas y clasificando la concordancia entre ambas.
Resultados: la población final fueron 109 alumnos (97,3%). El área competencial con mayor
concordancia fue juicio clínico (94,1%). Todos los ítems superaron el 65% de concordancia. Más
del 20% de los alumnos no habían registrado en sus HC algunos ítems, aunque los habían recogido
en la consulta. Anamnesis por órganos y aparatos fue el área competencial con más ítems
omitidos o incorrectos. El único ítem que ningún alumno olvidó recoger y registrar fue
«antecedentes personales de dislipidemia». Exploración física fue el área donde más alumnos
registraron hallazgos en la HC sin haberlos realizado en la entrevista.
Conclusión: el estudio demuestra la alta concordancia de la HC con la información recogida en
la consulta y descubre aspectos que nos permitirán mejorar la formación en semiología médica
de los alumnos.
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.
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.
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Keywords
Historia clínica, Registros médicos, Pacientes simulados, Simulación clínica, Estudiantes de Medicina