Identifying patients with a cancer diagnosis using general practice medical records and Cancer Registry data.
BACKGROUND
The medical records of patients with cancer need to accurately record diagnoses for professionals to provide quality care. Aims. (i) To develop a methodology which identifies medical records of patients with a cancer diagnosis. (ii) To describe the effectiveness of search strategies to identify all patients in primary care with a cancer diagnosis compared with a diagnosis identified by a Cancer Registry.


METHODS
The design of the study was a retrospective analysis of primary care medical records. Five general practices were recruited in the UK. The completeness and correctness of searches were measured and compared both within the practices and compared with a diagnosis identified by a Cancer Registry.


RESULTS
One in five of all primary care patients with cancer was not identified when a search for all patients with cancer was conducted using electronic codes for malignancy. One in five patient records with an electronic code for a malignancy that was confirmed by registration with the Cancer Registry actually lacked the necessary documentation to verify the cancer type, date of diagnosis or any other aspect of the malignant condition. Overall, electronic codes for cancer in these medical records have a poor level of completeness (29.4%) and correctness (65.6%) when compared with the Cancer Registry.


CONCLUSIONS
The electronic codes in five general practices were not able to identify all patients on the practice lists with a cancer diagnosis. Practices will only be able to comply with guidelines and meet quality targets if they can identify all of their current patients with a cancer diagnosis and will require information from a Cancer Registry in order to do this.
Centre for Primary Health Care and Equity, University of New South Wales, Sydney 2052, Australia. shanewpascoe@hotmail.com
Shane W
SW
Pascoe
Richard D
RD
Neal
Philip L
PL
Heywood
Victoria L
VL
Allgar
Jeremy Nv
JN
Miles
Jasmina
J
Stefoski-Mikeljevic
D005568:Forms and Records Control; D006801:Humans; D016247:Information Storage and Retrieval; D016347:Medical Records Systems, Computerized; D009369:Neoplasms / Q000175:diagnosis*; D011320:Primary Health Care; D012042:Registries; D012189:Retrospective Studies; D006113:United Kingdom