Resumo

MORENO RODRIGUEZ, Miguel A.. Deficiencias en la entrevista médica: Un aspecto del método clínico. Rev cubana med [online]. 2000, vol.39, n.2, pp.106-114. ISSN 0034-7523.

To assess, under direct visualization, medical interviews, performed by 48 internists in 96 inpatients, we used a list of 44 deficiencies. Such deficiencies concerning to HEA, types of questions, and general features, classified as mayor, important, and minor. There was a total of 783 deficiencies (media, 8.1 per interview) where 29.6 % corresponded to HEA, 20 % to types of questions, and 50,4 % to general features. 27 % were major, 46.4 % were important, and 26.6 % were minor. It was evident that there is a trend to obtaining information by means of brief and closed questions, inducing to responses and start by personal pathologic backgrounds, as well as serious difficulties in interrogation abilities. Some deficiencies must not arise so frequent in the last year of study. More than third of internists weren´t supervised just when they obtained data for medical record. We conclude that there is the need for increase direct visualization of students as a fundamental measure to improve their clinical abilities in making medical records

Palavras-chave : MEDICAL RECORDS; PHYSICAL EXAMINATION; CASE-CONTROL STUDIES.

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