[Improvement in the quality of the interclinic referral note in regard to the information given]

Abstract

Objective: To quantify the improvement in compliance with filling out the interclinical note after both general practitioners and specialists were informed of the compliance level found in an earlier study.

Design: An intervention before-and-after study. Unit of analysis: interclinical note in the primary care clinical record.

Setting: Health Areas 11 and 12 in the Community of Valencia, November 1993 and 1994. Field work was developed on the premises of the two specialist centres of these areas.

Participants: Two samples, of 708 and 326 interclinical notes, were used. These were stratified in function of the number of consultations during the first six months of each of the study years, by centre and speciality.

Intervention: All primary care and specialist professionals were informed of the level of compliance with the interclinical note in the first part of the study.

Main results: The primary care section improved significantly in: personal history, data on physical examination, suspected diagnosis, reason for consultation. The section on specialists improved significantly in the identification of the specialist, diagnosis, treatment, action to take.

Conclusions: Information given to professionals improved their filling out of the interclinical note, basically on variables to do with the pathological process. It should be routine to feed back information to the professionals concerned.