Medica Jadertina, Vol. 38 No. 3-4, 2008.
Izvorni znanstveni članak
Disease analysis after specialist examination: are there any differences in the medical history structure and contents in the period from 1999 to 2004
Vjekoslava Amerl-Šakić
; Zdravstvena stanica Jarun, Zagreb
Sažetak
Illegible and incomplete medical histories written by consultative polyclinic specialists are a great problem for family physicians. In the primary care unit in Trešnjevka, in the period from January 1 to
December 31, medical histories issued to patients by internists and surgeons in 1999 and 2004 were reviewed. Out of a total number of 4,288 medical histories, only 2,326 (54.24%) were complete and legible, whereas 864 (20.14%) were written by hand and more or less illegible for most physicians. According to the data obtained after more than 45% of all specialist exams, the primary care physician did not receive complete information regarding his/her patient's state. Though the total percentage without a correctly written diagnosis was high (12.55%), an even more worrisome fact was the 13.06% of medical histories without a completely specified therapy. A positive increase of 7.85% was noted, since in 2004 complete medical histories were entered more frequently. Statistically, the most significant difference was noticed in the medical histories without a fully specified therapy, where in 2004 internists wrote the therapy 3.06% more frequently in relation to 1999. A statistically significant difference was noted in comparing medical histories written in 2004 and 1999 among both internists and surgeons, and overall.
Ključne riječi
Medical history; specialist exam
Hrčak ID:
29483
URI
Datum izdavanja:
1.12.2008.
Posjeta: 14.573 *