The electronic patient record in primary care--regression or progression? A cross sectional study

摘要: Objectives To determine whether paperless medical records contained less information than paper based and that was harder to retrieve. Design Cross sectional study with review of interviews general practitioners. Setting 25 practices in Trent region. Participants 53 British practitioners (25 using 28 records) who each provided 10 consultations. Main outcome measures Content a sample doctor recall consultations for which or had been made. Results Compared records, more were fully understandable (89.2% v 69.9%, P=0.0001) legible (100% 64.3%, P < 0.0001). Paperless significantly likely have at least one diagnosis recorded (48.2% 33.2%, P=0.05), record advice given (23.7% vs 10.7%, P=0.017), and, when referral made, contain details the specialty (77.4% 59.5%, P=0.03). When prescription issued, specify drug dose (86.6% 66.2%, P=0.005). words, abbreviations, symbols (P 0.01 all). At interview, there no difference between groups proportion patients could be recalled. Doctors able (38.6% 26.8%, P=0.03). Conclusion We found evidence support our hypotheses would truncated local abbreviations; absence writing decrease subsequent recall. Conversely we compared favourably manual records.