OBJECTIVE: To describe the quality of general practitioner (GP) medical records. SUBJECTS AND SETTING: One hundred and fifty fee-for-service GPs in suburban Brisbane. SETTING OF STANDARDS: Standards were set at meetings with general practitioner educators, and refined after circulating drafts to participants. Criteria were established in the 12 areas of: general ease-of-use (legibility; consciousness; and layout); whether certain patient data could be found (date of birth; past medical history; family history; allergies; alcohol and tobacco use; and immunisation status); and whether information about the most recent consultation could be found, (the reason for the consultation; its assessment; and management). MAIN OUTCOME MEASURES: Ten randomly selected medical records of consultations from each of the GPs scored blind by medical students. RESULTS: The mean weighted score was 11.4 out of a maximum possible of 18. Most records attained the standard with: consciousness (97%); recording date of birth (94%); and immunisation status (92%). Fewest attained the standard with family history (12%); adequate layout (17%); and recording alcohol and tobacco use (31%). Practice size and membership of the Royal Australian College of General Practitioners were not associated with significant differences in score, although sex, (being female) and date of graduation, (recent), were associated with significantly higher scores. CONCLUSION: There is considerable room for improvement in the quality of the clinical records of Australian GPs.
RCT Entities:
OBJECTIVE: To describe the quality of general practitioner (GP) medical records. SUBJECTS AND SETTING: One hundred and fifty fee-for-service GPs in suburban Brisbane. SETTING OF STANDARDS: Standards were set at meetings with general practitioner educators, and refined after circulating drafts to participants. Criteria were established in the 12 areas of: general ease-of-use (legibility; consciousness; and layout); whether certain patient data could be found (date of birth; past medical history; family history; allergies; alcohol and tobacco use; and immunisation status); and whether information about the most recent consultation could be found, (the reason for the consultation; its assessment; and management). MAIN OUTCOME MEASURES: Ten randomly selected medical records of consultations from each of the GPs scored blind by medical students. RESULTS: The mean weighted score was 11.4 out of a maximum possible of 18. Most records attained the standard with: consciousness (97%); recording date of birth (94%); and immunisation status (92%). Fewest attained the standard with family history (12%); adequate layout (17%); and recording alcohol and tobacco use (31%). Practice size and membership of the Royal Australian College of General Practitioners were not associated with significant differences in score, although sex, (being female) and date of graduation, (recent), were associated with significantly higher scores. CONCLUSION: There is considerable room for improvement in the quality of the clinical records of Australian GPs.
Authors: Vari M Drennan; Mary Halter; Louise Joly; Heather Gage; Robert L Grant; Jonathan Gabe; Sally Brearley; Wilfred Carneiro; Simon de Lusignan Journal: Br J Gen Pract Date: 2015-05 Impact factor: 5.386