Format and content of medical record summaries in 27 training practices.
Twenty seven established trainers enrolled on an advanced course for trainers were sent a set of medical records with the instruction to summarize them as they would any set of records going into their practice. The main finding of the study was the great variability of the summaries produced, often owing to the failure to include important information from the continuation cards. The need for nationally recognized standards in summary making is discussed.
Presley
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D000043:Abstracting and Indexing; D004503:Education, Medical, Graduate; D004739:England; D005194:Family Practice / Q000193:education*; D005568:Forms and Records Control; D008499:Medical Records