Medical records and Primary Care: reflections on the biopsychosocial approach

Abstract

Based on the assumption that the quality of the medical report on the patient’s history may directly affect the qualities and characteristics of the treatment offered the patient – it may be used as a tool to assess it – this study is intended to assess the perception of primary care professionals concerning the relevance, appropriateness and availability of data in the medical reports on the patients’ history. Moreover, it is intended to check their perspectives as to what sort of data they find indispensable in order to assure that patients may have proper follow-up care. The overall perception grasped in this study deflagrates that, even though many professionals take into account social and psychological aspects in their practice, biological findings are predominant in medical records and this takes place even in primary care. There should be a different focus on the processes used to record patients’ information in the health system. Health professionals should take into account the biopsychosocial paradigm. Thus, medical records could reflect more comprehensive and complete approaches and practices, especially in relation to primary care, where these matters are of prime importance. Some reflections have been made in order to help and boost the creation of strategies and policies toward this purpose.