Evaluation of a data base sheet in an A4 medical record system

Abstract

The medical record system used by the author's general practice is in the A4 format and includes a structured summary sheet of their own design. In an evaluation of this data base sheet, the aims were twofold: to measure the extra time required to complete the A4 data base sheet during an interview with a patient against the time for an inspection of existing medical records alone; to quantify the usefulness of the data base sheet to the doctor seeking immediate access to relevant information about the patient's medical, family and social history.

Compilation of a structured A4 data base sheet took an average time of five and a half minutes per patient. Examination of NHS medical records took an average time of three minutes per record, and only 4 per cent of these records included any form of completed summary sheet. The data base sheet, which took only another two or three minutes to complete, was found to be a practicable document that provides immediate access to a wide range of relevant information for effective (and efficient) patient management.