Abstract
Introduction Home visits are a key component of primary care in Portugal, designed for patients unable to visit medical facilities. However, logistical constraints often lead to incomplete real-time clinical records, impacting care quality and safety. This study aimed to improve the quality of home visit records through structural interventions and a continuous quality improvement approach. Methods This study was conducted in a Portuguese family health unit between February and December 2023. This retrospective study involved all home visits performed by physicians from October 2022 to October 2023. Using the Plan-Do-Study-Act (PDSA) methodology, records were assessed based on four parameters: accuracy of the "Assessment" section of the Subjective, Objective, Assessment, and Plan (SOAP) note (aligned with the International Classification of Primary Care, 2nd edition); Barthel scale documentation; updated list of problems; and updated list of chronic medication. Data were collected, analyzed descriptively, and presented at three time points: baseline evaluation (February 2023), intermediate evaluation (July 2023), and post-intervention evaluation (December 2023). Two interventions were made, including educational sessions and the introduction of physical support tools for record-keeping. The established quality-defining goal was to achieve compliance with all four parameters in at least 80% of records. Results At baseline, none of the 97 evaluated records met all criteria. After two interventions, compliance significantly improved. By the final evaluation, 74.7% of 95 records met all criteria, while no records failed entirely. Discussion Despite not fully achieving the predefined goal, interventions significantly enhanced record quality, ranging from 0% to 74.7% at the end of the study. These findings demonstrate the value of structural interventions and collaborative team efforts in improving home visit records. Despite significant progress in improving home visit records, there is still room for improvement. It is essential for healthcare professionals to continue enhancing record-keeping practices to improve the effectiveness of domiciliary care and patient outcomes. Conclusion This study highlights the importance of accurate clinical records for safe and effective domiciliary care. Continued commitment to structured record-keeping practices and further research is essential to sustain improvements and optimize patient outcomes.