Assessment of the completeness and accuracy of computer medical records in four practices committed to recording data on computer.

摘要: BACKGROUND. General practice computer databases are being increasingly seen as a source of data for public health monitoring and commissioning. Such ambitions depend on routine clinical recorded with acceptable completeness accuracy. AIM. The aim this study was to assess the accuracy medical records in four high-recording general practices. METHOD. Four practices Trent Region that use EMIS system, were known be high recorders their databases, selected. A retrospective analysis records, prospective comparison sample manual between videorecorded consultations undertaken. RESULTS. Checks recording diabetes mellitus glaucoma showed levels accurate recording, 97% 92% respectively. Prevalence rates reasonably comparable. No consistently, across 10 diagnoses, prevalences higher or lower than other practices; those diagnoses recognized objective diagnostic criteria more consistent prevalence without. Lifestyle low; overall, smoking habits alcohol consumption 52% 38% patients aged over 16 years, Comparison sufficiently complete regard (82% all items recorded), prescriptions (100%) referrals (67%), but missed most remaining record captured. validation there no important lapses when compared actual process consultations. CONCLUSION. In these sufficient allow meaningful aggregation some referrals. Standardized protocols defining which included excluded from major disease groups required.