Hamilton William T, Round Alison P, Sharp Deborah, Peters Tim J
Division of Primary Health Care, University of Bristol.
Br J Gen Pract. 2003 Dec;53(497):929-33; discussion 933.
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.
To compare computer-only record keeping to paper-only and hybrid systems, by measuring the number of consultations and symptoms recorded within individual consultations.
Retrospective cohort study.
Eighteen general practices in the Exeter Primary Care Trust.
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.
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.
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.
基层医疗中的计算机化记录保存正在增加。然而，尚无研究系统地检查使用不同记录保存形式的医疗机构中计算机记录的完整性。
通过测量个体诊疗过程中记录的诊疗次数和症状数量，比较纯计算机记录保存与纯纸质记录保存及混合系统。
回顾性队列研究。
埃克塞特基层医疗信托基金的18家全科医疗机构。
本研究是一项针对40岁以上癌症患者的回顾性病例对照研究的一部分。确定了1396名患者在两年期间的所有记录诊疗，并进行编码。记录根据存储诊疗临床信息的介质分为纸质、计算机或混合记录。
混合系统记录的诊疗次数（两年中位数=11，四分位间距[IQR]=6 - 18）多于计算机系统（两年中位数=9，IQR=4 - 16.5）或纸质系统（两年中位数=8，IQR=5 - 14）：P<0.001。在一项包括年龄、性别和未来癌症诊断的泊松回归分析中，纸质和计算机系统记录的诊疗率分别比混合系统低16%和11%。纸质系统记录的电话诊疗较少，计算机系统记录的家访较少。计算机系统在个体诊疗中记录的症状较少。纸质系统中无症状和症状严重程度的记录最高。
基层医疗记录保存的混合系统记录的诊疗次数多于纯计算机或纯纸质系统。纯纸质系统中个体诊疗记录的质量最高。这具有法医学意义，可能会影响医疗连续性。
