Calidad de la información en las historias clínicas de personas con diabetes mellitus tipo 2 sobre el cuidado de los pies en centros de atención primaria de salud de Ecuador

Objective

To analyze the quality of information recorded in medical records, with an emphasis on foot care guidance for people with type 2 diabetes mellitus.

Design

Cross-sectional multicenter study.

Setting

Four primary care centers in Ecuador.

Participants

Medical records of 489 randomly selected individuals with type 2 diabetes mellitus.

Main measurements

Outcome variable: recording of care in four sections of the medical record: anamnesis, physical examination, complementary tests, and comprehensive evaluation. Explanatory variables: health center, age, and sex. Proportions and adjusted odds ratios (OR) were calculated using logistic regression with their confidence intervals.

Results

Of the 489 medical records, 57.9% were women. Twenty-three percent had no record of medical control, 98.2% lacked a podiatric assessment, 3.1% included an eye fundus exam, 4.3% had an electrocardiogram, and 7.6% had a psychosocial interconsultation. Being an older adult was associated with a higher likelihood of recording comorbidities (OR = 1.9), foot physical examination (OR = 1.7), neurological evaluation (OR = 2.9), and complementary tests (creatinine OR = 1.5, cholesterol OR = 1.8).

Conclusion

The study reveals poor quality in the clinical information recorded for individuals with diabetes, especially in podiatric assessments and the ordering of complementary tests. Older adults showed more complete records, highlighting the need to improve the consistency of care and recording for all patients. It is crucial to implement strategies that strengthen foot care guidance and the integrity of clinical records in the management of diabetes.