This study aims at evaluating the quality of medical records in primary health services of the Health District of Itapagipe (Salvador/Bahia, Brazil), before and after the health reform of the Unified and Decentralized Health System (SUDS), initiated in 1987. Nine hundred and sixty one new records for 1986 and 850 for 1989 were evaluated with regard to: standardization of the record, legibility, and adequate entry of basic information from the medical history on the first visit. Comparing the pre - and post - health reform periods, improvement was observed in relation to standardization of records (from 49% to 94%) as well as the recording of prescriptions and diagnoses (30% of the records without diagnoses had prescriptions in 1986, dropping to 7% in 1989). However, the proportion of legible records decreased slightly (from 76 % to 71 %) and there was a marked increase in the frequency of blank records (from 6% to 19%), indicating that, despite a better supply of material resources, there was not a corresponding progress in the quality of health information. Finally, even considering a marked improvement in the proportion of records with satisfactory quality (from 5 to 24%), one can still find in 1989 a very high proportion (49%) of records without registration of items from clinical examination.
Health Services Epidemiology; Health-services Evaluation; Health Information
