Summary

Objective: To study the pattern of medical records used among general practitioners.

Design: Cross-sectional study.

Subjects: All general practitioners who enrolled in a diploma course were requested to summit a sample record for analysis.

Main outcome measures: The designs of the records were checked for the provision for entry of ten important components. In addition, students were asked to hand in a photocopy of a recent consultation from their record and this was used for assessment on Legibility and Content Adequacy.

Results: The percentages of the ten components listed in the records were as follows:

1. Demographic data (97.5%),
2. Problem list (27.5%),
3. Screening checklist (11.3%),
4. Family pedigree (15.0%),
5. Chronic drug list (22.5%),
6. Drug allergy list (76.3%),
7. Social history (48.8%),
8. Family history (41.3%),
9. Immunisation history (22.5%),
10. Past health (62.5%). 45% of the records were legible and only 18.8% were judged to have adequate content. Solo practitioners were less likely to record problem list and screening checklist than doctors who work in groups or institutions.

Conclusion: The design of most of the medical records under study needs improvement. Problem list, chronic drug list and other important information should be included in the records. Good records help to organise the doctor's thinking and are important medical and legal documents to facilitate high quality continuing patient care. Doctors in primary care are strongly urged to learn more about good record keeping and practice it in their daily work.

Keywords: General practice, medical record

摘要

目的：研究全科醫生的醫療紀錄模式。

設計： 橫切面式研究。

對象：就所有參予家庭醫學文憑課程的全科醫生所提 交的醫療紀錄樣本加以分析。

測量內容：檢視所提交的醫療紀錄有否包含十大要 點。同時分析近期診症紀錄，評估其內容是否清楚及適當。

結果：醫療紀錄包括的十大要點的情況如下：

1. 人口統計資料 (97.5%)，
2. 問題表(27.5%)，
3. 普查清單(11.3%)，
4. 家族系表 (15.0%)，
5. 長期用藥清單(22.5%)，
6. 藥物敏感清單(76.3 %)，
7. 社會史(48.8%)，
8. 家族史(41.3%)，
9. 免疫紀錄(22.5 %)，
10. 過往病史(62.5%)。45%之病史紀錄被評為內容清晰，但只有 18.8%之紀錄內容適當。團體執業者較個人執業者注重問題表和普查清單。

結論：絕大部份醫療紀錄的設計需要改善。問題表及長期服藥清單等應列入紀錄內。良好的醫療紀錄不但 有助醫生思考，同時也是重要的醫學及法律文件，能有效維持高水準的醫療服務。因此應極力推動基層醫 生對良好醫療紀錄加強認識和應用。

主要詞彙：全科醫生，醫療紀錄

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Introduction

The medical record is an important tool for practicing medicine. It records the findings, diagnoses and management of the patient. When the record grows with time, it serves as a tool for monitoring the progress of diseases and for planning continuity of care. With a good design, the medical record can help in disease prevention by providing a tool for identifying at-risk patients and also a recall database for preventive services. The author tried to study the medical records kept by some local general practitioners.

Method

All general practitioners who enrolled in a diploma course were requested to submit a new medical record for analysis. The record design was checked for the provision for entry of the following components:

1. Demographic data
2. Problem list
3. Screening check list
4. Family pedigree
5. Chronic drug list
6. Drug allergy list
7. Social history
8. Family history
9. Immunisation history
10. Past health

In addition, participants photocopied the record of their most recent consultation for analysis of:

11. Legibility
12. Content Adequacy

If more then 80% of the words could be recognised, the record was classified as legible. If the consultation record contained a description of the chronological events of the patient's presenting problems, significant positive and negative findings, a working hypothesis of the patient's problems and their interventions, the consultation record was classified as content adequate.

Results

Demographic characteristics

Eighty students came from different geographical areas across the whole of Hong Kong. They had a very wide age-range and wide standard deviations in years after graduation and years of general practice (Table 1). Students also had a diversified working background with over 80% coming from the private sector and that nearly 60% were solo practitioners (Table 2). These indicated that the students had a wide representation across the whole spectrum of general practitioners working in the community.

Table 1: Analyses of the students' demographic data
	Minimum	Maximum	Mean and standard deviation
Age	27	66	39.1 9.3
Years after graduation	3	39	13.2 8.6
Years of general practice	0	36	7.5 7.0

Table 2: Working background of the students
	Working background	Number	% of total
Private sector	Solo practice	47	58.8%	81.3%
	Private institution	6	7.5%
	Private group practice	12	15.0%
Public sector	OPD of the Department of Health	4	5.0%	16.3%
	OPD / Staff Clinic of the Hospital Authority	4	5.0%
	Other public institutions	5	6.3%
Unclassified	Locum	1	1.3%	2.5%
	Retired	1	1.3%
		Total: 80	100%	100%

Record quality

There were a total of 80 medical record samples and 80 consultation record photocopies. They were checked against the 12 quality components. The percentages of the ten components found in the records were tabulated in Table 3. Further analysis showed that medical records from non-solo practitioners had significant higher percentages among components in problem list, screening check list, social history and family history.

Table 3: Frequency of the quality components
		Type of practice
Quality component	Total (%) N=80	Solo (%) N=49	Non-solo (%) N=31	X2 p-value
Demographic data	78 (97.5)	47 (95.9)	31 (100.0)	0.86
Problem list	22 (27.5)	8 (16.3)	14 (45.2)	0.02*
Screening check list	9 (11.3)	2 (4.1)	7 (22.6)	0.02*
Family pedigree	12 (15.0)	8 (12.9)	4 (12.9)	0.70
Chronic drug list	18 (22.5)	10 (20.4)	8 (25.8)	0.62
Drug allergy list	61 (76.3)	34 (95.9)	27 (100.0)	0.86
Social history	39 (48.8)	17 (34.7)	22 (71.0)	0.02*
Family history	33 (41.3)	14 (28.6)	19 (61.3)	0.03*
Immunisation history	18 (22.5)	10 (20.4)	8 (25.8)	0.62
Past health	50 (62.5)	26 (53.1)	24 (77.4)	0.18
Legibility	36 (45.0)	21 (42.9)	15 (48.4)	0.72
Content adequacy	15 (18.8)	6 (12.2)	9 (29.0)	0.09
* Statistically significant

Discussion

There were deficiencies in the design of most of the medical records submitted for study. Only demographic data, drug allergy list and past health were present in more than 50% of the records. Only 27.5% of the medical records were designed for entry of a problem list.

Problem list is the key component in a medical record and all medical records should contain a summary of all significant and continuing problems.¹ Recording the patient's health data in the form of a list of the health problems identified, each matched with the corresponding subjective and objective assessments, the interventions and plans of management is the skeleton of a Problem Orientated Medical Record. Implementing such method of recording was found to improve the quality of documentation and also improve the professional accountability and credibility of interventions.² This study showed that only 16.3% of the medical records from solo practitioners had a problem list. Although a significantly higher percentage (45.2%) was found in the non-solo group, given the importance of the problem list in a medical record, this figure was still low.

Records with screening checklist can act as a reminder to doctors to practice preventive care. Evidence shows that reminder is one of the most effective methods to induce behavioural changes among doctors.³ Overall, only 11.3% of the medical records in this study provided for a screening checklist. Medical records from the non-solo group had a higher percentage (22.6%), but the figure was still low.

While medical records used by solo practitioners were designed by the doctors themselves, most of the records used by non-solo practitioners were provided by the institutions. Most institution medical records included the social history and family history, as they were traditionally part of the patient's medical history. This explained why medical records from the non-solo group had a significantly higher percentage of social (71.0%) and family history (61.3%) than those from the solo group. However, the design of some of these institution medical records was very old and therefore problem lists and screening checklists were not included. When they were present, they were found mainly in medical records from family medicine training centers.

Legibility and Content Adequacy are the other two areas of concern. Although thoroughness of documentation is not associated with clinical outcomes and there is a very weak relationship between content adequacy and patient satisfaction or provider-patient interactions,⁴ a legible medical record with adequate content is essential both as a medicolegal document and also as a tool for ongoing patient care.⁵ Only 45% of the medical records in this study were assessed to be legible and only 18.8% of the medical records had adequate content.

One limitation of this study was that the author could only assess if spaces had been provided in the medical records for the selected component. For example, if there was no space for drawing the family pedigree and there was no heading of family pedigree printed on the medical record, the author could only assume that the parameter of family pedigree in that medical record was missing. Doctors could have drawn the family pedigree on a separate progress sheet. On the other hand, the presence of pre-printed space or heading for a parameter on the medical record does not mean the doctor would actually record that parameter.

The author had proposed a sample medical record in 1987⁶ and later The Hong Kong College of Family Physicians also introduced a sample medical record for general practitioners in 1989. While doctors have to upgrade themselves with continuing medical education and continuous professional development,⁷ the medical record, being an important tool in our armament, has to be updated as well. Although it may be costly to replace all existing medical records, additional sheets may be used to supplement the deficient areas while waiting for the newly designed medical records to be introduced after the old stock has been used up. With the advancement of medical informatics and computers, computerisation of medical records is the direction of the future and will gain popularity once the problems with data security and confidentiality are solved. While the format of data recording may be different between a hand written and a computerised medical record, the criteria of a good medical record are the same. A good computerised medical system should improve the quality of medical records⁸ and be able to provide the same, if not more, components than hand written medical records.

Conclusion

Most of the medical records under study need improvement. Problem list, chronic drug list and other important information should be included in the records. Doctors in primary care are strongly urged to learn more about good record keeping and practice it in their daily work.

Acknowledgements

The author would like to thank the Department of Community & Family Medicine, The Chinese University of Hong Kong for the permission to use the data from the Diploma of Family Medicine course and for the support and suggestions in preparing this manuscript.

Key messages

1. The design of most of the medical records under study needs improvement.
2. Problem list and chronic drug list etc should be included in the records.
3. Good records help to organise the doctor's thinking and are important medical and legal documents to facilitate high quality continuing patient care.
4. Additional sheets may be used to supplement the deficient areas while waiting for replacement by the newly designed medical records.
5. A good computerised medical system should improve the quality of medical records.

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References