General Practice Observed: Survey of General Practice RecordsBr Med J 1972; 3 doi: https://doi.org/10.1136/bmj.3.5820.219 (Published 22 July 1972) Cite this as: Br Med J 1972;3:219
- K. S. Dawes
A study of a sample of records from eight general practices showed that 10% of patients' ages were not recorded, that 99% of males had no indication of their marital state, and 60% did not have an occupation recorded. In recording of disease episodes a diagnosis was recorded in a little over half of the episodes and was the only recorded item in 10% of records. The recording of the therapeutic agent used was the most frequently recorded item, occurring in 70% of episodes, but the amount prescribed was recorded in only one-quarter of the episodes and the dosage in less than one-fifth. Less than half of the episodes had any symptoms recorded and only one-third had a physical sign recorded.