Integrated record keeping as an essential aspect of a primary care led health service (original) (raw)
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Primary Care Patient Records in the United Kingdom: Past, Present, and Future Research Priorities
JOURNAL OF MEDICAL INTERNET RESEARCH, 2018
This paper briefly outlines the history of the medical record and the factors contributing to the adoption of computerized records in primary care in the United Kingdom. It discusses how both paper-based and electronic health records have traditionally been used in the past and goes on to examine how enabling patients to access their own primary care record online is changing the form and function of the patient record. In addition, it looks at the evidence for the benefits of Web-based access and discusses some of the challenges faced in this transition. Finally, some suggestions are made regarding the future of the patient record and research questions that need to be addressed to help deepen our understanding of how they can be used more beneficially by both patients and clinicians.
2018
UNSTRUCTURED This paper briefly outlines the history of the medical record and the factors contributing to the adoption of computerized records in primary care in the United Kingdom. It discusses how both paper-based and electronic health records have traditionally been used in the past and goes on to examine how enabling patients to access their own primary care record online is changing the form and function of the patient record. In addition, it looks at the evidence for the benefits of Web-based access and discusses some of the challenges faced in this transition. Finally, some suggestions are made regarding the future of the patient record and research questions that need to be addressed to help deepen our understanding of how they can be used more beneficially by both patients and clinicians.
British Journal of General Practice
Background: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. Aim: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. Design of study: Retrospective cohort study. Setting: Eighteen general practices in the Exeter Primary Care Trust. Method: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, dependi ng on which mediu m st ored the clinical information from consultations. Results: More consultations were recorded in hybrid systems (median in 2 years = 11,
British Journal of General Practice, 2004
Background: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. Aim: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. Design of study: Retrospective cohort study. Setting: Eighteen general practices in the Exeter Primary Care Trust. Method: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, dependi ng on which mediu m st ored the clinical information from consultations. Results: More consultations were recorded in hybrid systems (median in 2 years = 11, interquartile range [IQR] = 6-18) than computer systems (median in 2 years = 9, IQR = 4-16.5) or paper systems (median in 2 years = 8, IQR = 5-14,): P<0.001. In a Poisson regression analysis, which included age, sex, and future cancer diagnosis, the rates of consultations recorded in paper and computer systems were 16% and 11% lower, respectively, than in hybrid systems. Fewer telephone consultations were recorded in paper systems, and fewer home visits in computer systems. Fewer symptoms were recorded in individual consultations on computer systems. Recording of absent symptoms and severity of symptoms was highest in paper systems. Conclusion: Hybrid systems of primary care record keeping document higher numbers of consultations than computer-only or paper-only systems. The quality of individual consultation recording is highest in paper-only systems. This has medicolegal implications and may impact upon continuity of care.
Continuity of care through medical records--an explorative study on GPs' management considerations
Family Practice, 2006
Schers H, van den Hoogen H, Grol R and van den Bosch W. Continuity of care through medical records-an explorative study on GPs' management considerations. Family Practice 2006; 23: 349-352. Background. The growing complexity of care with more professionals involved is a threat to the delivery of coherent and consistent care. Excellent exchange of information between professionals may be a way to maintain continuity of care. Relevant information to be passed over includes thoughts about future management for individual patients. Aim. To explore the nature of GPs' thoughts about future management, and to determine the extent to which such thoughts are actually recorded in medical records.
Data recording in primary care field studies: Patient records enhancement project
2011
This position paper describes the Human-Computer Interaction (HCI) field studies component of the multidisciplinary Patient Records Enhancement Project (PREP). PREP seeks to understand variability of data found in primary care electronic records, in particular the balance between coded data and doctor's 'free text' notes. HCI fieldwork will establish variables that affect recording practices. In field studies we observe and record data recording practices in general practice (GP) surgeries, interview staff, video consultations with real patients and video consultations with standardized patients (played by medical actors). By standardizing patients we can compare the impact of other variables: different doctors, in different surgeries, using different e-health systems. Our early findings suggest that variability is due to a complex web of reasons, driven by personal, contextual and organizational processes. Findings from thematic analysis will result in design implications for studies by epidemiologists and public health researchers, design of NHS training and work processes, and design of electronic health record interfaces.
Managing Medical Records in Specialist Medical Centres
International Journal of Engineering & Technology, 2018
A collection of facts about a patient's life and health history of past and present illnesses and treatments is known as medical records. The health professionals were contributing to record the patient's care. The responsibility in managing daily records that produced by each of department is by the Medical Records Department. It is a department under clinical support services with activities including managing of patient records, patient information production, management of medical reports, and hospital statistics. This article aims to discuss the challenge associated with managing medical records in the organization and how to handle and manage it with the records management as a tool to mitigate risk. Therefore, it is likely to prompt further research by addressing existing gaps towards improving service delivery that can contribute to the body of knowledge in the field of records management and archives generally.
Social Science & …, 2010
The primary care consultation provides access to the majority of health care services and is central to obtaining diagnoses, treatment and ongoing management of long-term conditions. This paper reports the findings of an interdisciplinary feasibility study to explore the benefits and practical, technical and ethical challenges (and solutions) of creating a longitudinal database of recorded GP consultations in Tayside, Scotland which could be linked to existing routine data on intermediate and long-term health outcomes. After consultation we attempted to recruit and audio-record the consultations of all patients attending three general practices over a two week period. Background patient data, and patient and staff experiences of participation were also collected. Eventually, two practices participated with 77% of patients approached agreeing to participate. The findings suggest that the perceived integrity of the consultation was preserved. The overwhelming majority of patients believed that recording was worthwhile and did not feel it impacted on communication or the treatment they received; 93% indicated they would be willing to have subsequent consultations recorded and 81% would recommend participation to a friend. Staff had similar beliefs but raised concerns about potential increases in workload, confidentiality issues and ease of software use. We conclude that practice participation could be increased by providing safeguards on data use, financial reward, integrated recording software, and procedures to lessen the impact on workload. The resulting Scottish Clinical Interactions Project (SCIP) would provide the largest and most detailed longitudinal insight into real world medical consultations in the world, permitting the linking of consultation events and practices to subsequent outcomes and behaviours.
Electronic access to a summary of key details from a patient's medical record from wherever they are being treated is a goal of many health systems. England, Scotland and Wales addressed this by developing the Summary Care Record, Emergency Care Summary and Individual Health Record respectively; Northern Ireland adopted Scotland's technology. Whilst all four schemes shared a similar vision, they differed widely in their strategy, budget, implementation plan, approach to clinical and public engagement and approach to evaluation and learning. We compare the four countries' experiences and draw lessons from the mixed fortunes of these programmes to date.