Research Article

Evaluation of quality of contents of general practice records.

Br Med J (Clin Res Ed) 1984; 289 doi: http://dx.doi.org/10.1136/bmj.289.6436.26 (Published 07 July 1984) Cite this as: Br Med J (Clin Res Ed) 1984;289:26
  1. S J Jachuck,
  2. P Price,
  3. C L Bound

    Abstract

    The quality of contents of general practice records was assessed by retrieving clinical information pertaining to hypertension in 171 consecutive records, and the quality of communication storage was assessed by seeking evidence of tuberculin skin tests or BCG vaccination, or both, in 298 consecutive records. There was no mention of urine analysis and blood test results in 43.3% and no record of fundal examination in 61.4% of the records of patients with hypertension. Electrocardiography was performed in 67.8% and chest x ray examination was done in 65.5% of these patients. These observations have importance for patient care, education, and research. The information regarding tuberculin skin test or BCG immunization, or both, was not available in 78% of the records. Reassessment of the individuals, however, showed that 89% of the studied population had had the test or vaccination, or both. There was thus a deficiency in communication and storage.