Ellis P M, Blackshaw G, Purdie G L, Mellsop G W
Department of Psychological Medicine, Wellington School of Medicine, University of Otago, New Zealand.
Med Educ. 1991 Sep;25(5):438-43. doi: 10.1111/j.1365-2923.1991.tb00092.x.
Deficiencies in recording clinical information are a widespread problem in both psychiatry and medicine. Previous studies have not established whether information not recorded in the notes is nonetheless known to clinicians. This study compared both the information known to individual clinicians and that recorded in the notes with previously established criteria. Overall, individual clinicians recalled more information than was recorded in the notes (median values: clinicians 47-63% of criteria; notes 42%) and when all this individual knowledge was pooled, 88% of the preset criteria were satisfied. Consultants, but not more junior staff, recalled significantly more about subsections of the history which they considered to be especially relevant to the management plan for a given patient. Only a third of data not known to clinicians, but thought by them to be recorded in the notes, was actually present. The implications of these findings for clinical audit and medical education are discussed.
