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Intended for Healthcare Professionals
British Journal of General Practice

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Research Article

The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems.

William T Hamilton, Alison P Round, Deborah Sharp and Tim J Peters
British Journal of General Practice 2003; 53 (497): 929-933.
William T Hamilton
Division of Primary Health Care, University of Bristol. w.t.hamilton@btopenworld.com
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Alison P Round
Division of Primary Health Care, University of Bristol. w.t.hamilton@btopenworld.com
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Deborah Sharp
Division of Primary Health Care, University of Bristol. w.t.hamilton@btopenworld.com
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Tim J Peters
Division of Primary Health Care, University of Bristol. w.t.hamilton@btopenworld.com
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Abstract

BACKGROUND: Computerised record keeping in primary care is increasing. However, no study has systematically examined the completeness of computer records in practices using different forms of record keeping. AIM: To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations. DESIGN OF STUDY: Retrospective cohort study. SETTING: Eighteen general practices in the Exeter Primary Care Trust. METHOD: This study was part of a retrospective case control study of cancer patients aged over 40 years. All recorded consultations for a 2-year period were identified and coded for 1396 patients. Records were classified as paper, computer, or hybrid, depending on which medium stored the clinical information from consultations. RESULTS: More consultations were recorded in hybrid systems (median in 2 years = 11, interquartile range [IQR] = 6-18) than computer systems (median in 2 years = 9, IQR = 4-16.5) or paper systems (median in 2 years = 8, IQR = 5-14,): P <0.001. In a Poisson regression analysis, which included age, sex, and future cancer diagnosis, the rates of consultations recorded in paper and computer systems were 16% and 11% lower, respectively, than in hybrid systems. Fewer telephone consultations were recorded in paper systems, and fewer home visits in computer systems. Fewer symptoms were recorded in individual consultations on computer systems. Recording of absent symptoms and severity of symptoms was highest in paper systems. CONCLUSION: Hybrid systems of primary care record keeping document higher numbers of consultations than computer-only or paper-only systems. The quality of individual consultation recording is highest in paper-only systems. This has medicolegal implications and may impact upon continuity of care.

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British Journal of General Practice: 53 (497)
British Journal of General Practice
Vol. 53, Issue 497
December 2003
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The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems.
William T Hamilton, Alison P Round, Deborah Sharp, Tim J Peters
British Journal of General Practice 2003; 53 (497): 929-933.

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The quality of record keeping in primary care: a comparison of computerised, paper and hybrid systems.
William T Hamilton, Alison P Round, Deborah Sharp, Tim J Peters
British Journal of General Practice 2003; 53 (497): 929-933.
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Print ISSN: 0960-1643
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