How bad are medical records? A review of the notes received by a practice.
One hundred and fifty-five medical records received by a practice as a result of transfer of care were examined. It was found that the marital status was recorded for 30% of patients aged over 16 years and the occupation noted for only 15% of patients of working age. Twentythree per cent of the notes included a summary of the patient's history and 39% contained an immunization record. Of the notes for women aged between 16 and 60 years 48% contained a recent cervical smear report. This percentage increased to 61% for women aged 35-60 years. Of the entries examined 86.2% were legible. It is concluded that either doctors do not know as much about their patients as they should or they attempt to carry too much information in their heads.
D000293:Adolescent; D000328:Adult; D004739:England; D005194:Family Practice; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged