General Practice Records.
نویسنده
چکیده
"One has reached the conclusion that the key to good general practice is the keeping of good clinical records," says Dr. Stephen Taylor in " Good General Practice." And again, " Doctors who claim that they can carry in their heads all the information needed to deal with each of their patients usually have low standards of both need and performance." On reading through the notes one receives about patients from some practitioners, one is often struck by the thought that not only are they of very little use now, but they must have been of little use at the time to those who made them. Poor note-taking is a waste of time; on the other hand, good notes are a sound investment, they save time and are the key to leisure. It is the purpose of this memorandum to look into some of the common failings of our record keeping, and to suggest improvements and innovations that might be given a trial. No attempt to standardize note-taking is intended, but there are a few principles that might usefully be followed. The Purpose of Notes Notes serve three possible functions-to be an aide-memoire to the note writer, a guide to later practitioners handling the patient, and a help to the writer's partners and assistants. Notes written as an aide-medmoire are the shortest; and it is suggested that too much emphasis should not be laid oIn writing notes for the benefit of later practitioners and more emphasis should be laid on providing them with a brief summary of the patient's history. In the notes made by a practitioner for himself, it ought to be possible to refer back easily to an incident without having to wade through pages of manuscript in which prescriptions are mixed up with clinical findings and important diagnoses are buried among trivial details.
منابع مشابه
How well do family practitioner committee and general practice records agree? Experience in a semi-rural practice.
General practice notes may be inaccurate for various reasons. A study was carried out in one semi-rural practice to investigate the agreement between records held by the family practitioner committee and those kept in the practice. Details on the practice notes and the family practitioner committee list were compared for 800 patients. The details examined included name, sex, date of birth, addr...
متن کاملConfidentiality of medical records: the patient's perspective.
BACKGROUND The development of modern information technology and the increasing amount of multidisciplinary teamwork in primary health care mean that the principle of patient confidentiality is becoming difficult to uphold. The debate about confidentiality so far has paid little attention to patients' views. AIM A qualitative study was undertaken to explore patients' expectations and attitudes...
متن کاملA survey of validity and utility of electronic patient records in a general practice.
OBJECTIVE To develop methods of measuring the validity and utility of electronic patient records in general practice. DESIGN A survey of the main functional areas of a practice and use of independent criteria to measure the validity of the practice database. SETTING A fully computerised general practice in Skipton, north Yorkshire. SUBJECTS The records of all registered practice patients....
متن کاملPatients' own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study.
OBJECTIVE To investigate the relation between older patients' assessments of the quality of their primary care and measures of good clinical practice on the basis of data from administrative and clinical records. DESIGN Cross sectional population based study using the general practice assessment survey. SETTING 18 general practices in the Basildon primary care trust area, south east England...
متن کاملThe Wellcome Trust Report: moving forward the use of general practice electronic patient records for research.
متن کامل
Childhood accidents: a practice survey using general practitioners' records and parental reports.
A survey of accidents in children under 16 years of age from one general practice (list size 6400) was carried out using a postal questionnaire to parents and an audit of medical records. Incidence rates were estimated by audit of medical records as 97% of accidents 'other than minor cuts and bruises' reported by parents had resulted in a medical consultation, and parental reporting was incompl...
متن کاملذخیره در منابع من
با ذخیره ی این منبع در منابع من، دسترسی به آن را برای استفاده های بعدی آسان تر کنید
عنوان ژورنال:
- Research newsletter. College of General Practitioners
دوره 7 شماره
صفحات -
تاریخ انتشار 1955