Çukurova University Training Family Health Center's two-years electronic health records profile: A retrospective analysis

Objective: The study aims to retrospectively analyze the health records of Çukurova University Training Family Health Center Unit 047 in the two years since its establishment. Method: The electronic health records of individuals who applied to the Unit between 01.08.2018 and 01.08.2020 were surveyed. All records in the defined time interval were evaluated in the electronic files containing the sociodemographic data of the individuals, their complaints, examination notes, diagnoses, and the number of procedures by month in the Unit. Results: The current 2970 applications were determined to be 1395 individuals. The average number of applications per person was found to be 2.12. Of the applicants, 53.4% were women. 65.2% of individuals with a mean age of 32.2±15.4 were single. It was determined that smoking status was not recorded at a rate of 55.5%. It was observed that the rate of recording smoking and alcohol consumption was higher in applications for a health report. The rate of smoking was 16.4% in individuals with a cigarette record. It was found that the rate of smoking cessation was higher in married individuals (p<0.001). The alcohol consumption was significantly higher in men (13.9%, p<0.001). There was no difference in alcohol consumption in terms of marital status. The most common causes of application were medical reports (15.9%), prescription refills (7.0%), and biochemical blood analysis (5.7%). The rate of recording the reason for application information by the physician was 56.7%. The most common diagnoses were upper respiratory tract infections (22.2%), medical reports application (19.3%), and general control examinations (13.6%). It was observed that there were inconsistencies between the reason for admissions and the diagnosis. Conclusion: It was noticed that the Unit predominantly provide serves to young individuvals. It was determined that the examination notes were not kept in SOAPE format, the physicians were lacking in terms of ICD code authoring, and the electronic health record program used in our Unit had aspects that needed to be improved. Keywords: Training Family Health Center, Electronic Health Record, Family Medicine, Patient Profile, SOAPE, ICD