Survey of general practice records

Abstract

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.