This study is based on a medical audit of the Vila Municipal Health Clinic, Pelotas, Rio Grande do Sul. We collected data from family medical records in 1992, 1993, and 1994. The data concerned the Women's Integral Health Care Program. We collected information on age, visits for medical and non-medical reasons, blood pressure, breast examination, coverage of Pap smear testing, and contraceptive methods. On average, women visited the clinic 3.5 to 4 times a year; 53% of the women were between 20 and 39 years of age; 42.5% of the women had had a Pap smear in the previous three years; 19% of the women had had their breasts examined. Blood pressure measurement was the most common procedure recorded in this clinic. We believe quality of medical records is a factor in patient care. We expect a critique of the low-quality medical records found in this audit can serve as the basis for a discussion among the health care team, with a view towards improving medical care, thereby benefiting patients.
Medical Audit; Medical Records; Women's Health; Health Care
