How bad are medical records? A review of the notes received by a practice

Abstract

One hundred and fifty-five medical records received by a practice as a result of transfer of care were examined. It was found that the marital status was recorded for 30% of patients aged over 16 years and the occupation noted for only 15% of patients of working age. Twentythree per cent of the notes included a summary of the patient's history and 39% contained an immunization record. Of the notes for women aged between 16 and 60 years 48% contained a recent cervical smear report. This percentage increased to 61% for women aged 35-60 years. Of the entries examined 86.2% were legible. It is concluded that either doctors do not know as much about their patients as they should or they attempt to carry too much information in their heads.