The electronic patient record in primary care—regression or progression? A cross sectional studyBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7404.1439 (Published 26 June 2003) Cite this as: BMJ 2003;326:1439
Appendix: Definitions used in assessing medical records:
Numbers of words, numbers, abbreviations, symbols, and drawings:
A word is any whole (not abbreviated) word. All words on the consultation record should be counted. Do not include name of surgery. The name of the GP or his or her initials should be counted in the initials field. If no words appear enter 0.
A number would have come from taking the history—for example, the number of episodes or the duration of an illness in days, the number of tablets, or numbers of siblings. It does not include blood pressure readings or body mass index readings—these are values. If no numbers are recorded enter 0.
An abbreviation is any abbreviation of a whole word used—for example, ct, ref, Ix, &, £, L (also when in a circle), R (also when in a circle), c. See attached sheets for full list of abbreviations. If no abbreviations are recorded enter 0.
A symbol is used to represent a word. The following represents all the symbols to be included ü , ?, ??, +, ++, +++, ++++, %, ° , λ , ® , ¯ , # , ∗ , =, +/-, x, < , Δ , ¿ . If no symbols are recorded enter 0.
A drawing is any illustrative representation in the notes. It is cruder than a symbol and is open to interpretation. If no drawings are recorded enter 0. Examples of a drawing:
If there is an entry, for example, the circle is to count as a drawing and 60 as a single value.
For previous medical history include any mention of a condition that the patient has had previously or still has but is not the reason for encounter—for example, previous MI. Include only explicit recording rather than inference. It means any positive or negative previous events.
For symptoms include any symptoms described in the record—for example, "He came with a cough and complaining of breathlessness."
For social history include, for example, discussions about housing, employment, money, marital issues, family, etc.
For advice given include any comments indicating that the doctor offered the patient general advice—for example, "I told him to take it easy for a while" or "I told her not to do any sport for a month" or "I gave some advice on his inhalers."
For patient views include all references to a patient’s views—for example, evidence of what patient wants or expects from the consultation: "The patient came in wanting some reassurance," "She thought she should be put on the waiting list."
For lifestyle information include references to smoking, alcohol consumption, exercise.
- This Week In The BMJ Published: 26 June 2003; BMJ 326 doi:10.1136/bmj.326.7404.0-b
- Primary CareRisk of adverse gastrointestinal outcomes in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysisPublished: 01 December 2005; BMJ 331 doi:10.1136/bmj.331.7528.1310
- Primary CareEffect of combinations of drugs on all cause mortality in patients with ischaemic heart disease: nested case-control analysisPublished: 05 May 2005; BMJ 330 doi:10.1136/bmj.330.7499.1059
- Letter Published: 11 September 2003; BMJ 327 doi:10.1136/bmj.327.7415.622-b
- Analysis And Comment Published: 29 June 2006; BMJ 333 doi:10.1136/bmj.333.7557.39
- Student Published: 01 March 2005; BMJ 330 doi:10.1136/sbmj.0503104
- Welsh GPs are awarded 3% pay riseBMJ December 03, 2021, 375 n3009; DOI: https://doi.org/10.1136/bmj.n3009
- Plans to reform adult social care fall short of promises, say criticsBMJ December 02, 2021, 375 n2980; DOI: https://doi.org/10.1136/bmj.n2980
- Elective care backlog could rise to 12 million patients by 2025, warns watchdogBMJ December 01, 2021, 375 n2977; DOI: https://doi.org/10.1136/bmj.n2977
- Aducanumab: 4 in 10 high dose trial participants experienced brain swelling or bleedingBMJ December 01, 2021, 375 n2975; DOI: https://doi.org/10.1136/bmj.n2975
- Helen Salisbury: Omicron—panic mongering or appropriate caution?BMJ November 29, 2021, 375 n2941; DOI: https://doi.org/10.1136/bmj.n2941
- Medicines reconciliation in primary care: a study evaluating the quality of medication-related information provided on discharge from secondary care
- Investigating the epidemiology of medication errors in adults in community care settings: A retrospective cohort study in central Saudi Arabia
- Using information technology to control STIs
- Gradual Electronic Health Record Implementation: New Insights on Physician and Patient Adaptation
- The Kaiser Permanente Electronic Health Record: Transforming And Streamlining Modalities Of Care
- Inequalities in the primary care of patients with coronary heart disease and serious mental health problems: a cross-sectional study
- Management of type 2 diabetes with multiple oral hypoglycaemic agents or insulin in primary care: retrospective cohort study
- Patients should have to opt out of national electronic care records: FOR
- Effect of statins on the mortality of patients with ischaemic heart disease: population based cohort study with nested case-control analysis
- Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis
- Risk of adverse gastrointestinal outcomes in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis
- What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study
- Improving evidence based cardiac care and policy implementation over the patient journey: the potential of coronary heart disease registers
- Recent changes in the prevalence of diseases presenting for health care
- Effect of combinations of drugs on all cause mortality in patients with ischaemic heart disease: nested case-control analysis
- Electronic health records
- Association of deprivation, ethnicity, and sex with quality indicators for diabetes: population based survey of 53 000 patients in primary care
- Electronic patient records in primary care: Study has serious flaw