Case notes as indicators of the prevailing medical model: implications.
The level of recording of relevant psychosocial parameters in 50 randomly selected medical and surgical case notes in a general teaching hospital was measured and compared with that of similar data recorded 10 years ago. In spite of wide acknowledgment of the importance of data of this kind, the frequency of recording was low and the only changes over the 10-year period were modest increases in the frequency of recording of alcohol intake and of occupation. These findings are discussed with reference to the surveyed opinion of the junior hospital medical staff. The suggestion is made that the model of illness currently in use in hospitals has not yet assimilated these dimensions and that belief to the contrary may be illusory. The implications for the role of psychiatrists in undergraduate and continuing education is noted, as is the possible relevance of the findings to medical economics and manpower needs.
D000328:Adult; D000368:Aged; D000428:Alcohol Drinking; D001291:Attitude of Health Personnel; D001294:Attitude to Health; D004644:Emotions; D005190:Family; D005260:Female; D006801:Humans; D008297:Male; D008487:Medical History Taking / Q000639:trends; D008499:Medical Records / Q000639:trends; D008606:Mental Processes; D009520:New Zealand; D009790:Occupations; D010820:Physicians