Bradley Stephen H, Lawrence Neil R, Carder Paul
York Street Practice, Leeds, UK.
Academic Unit of Primary Care, University of Leeds, Leeds, UK.
Future Healthc J. 2018 Oct;5(3):207-212. doi: 10.7861/futurehosp.5-3-207.
In contrast to secondary care, where handwritten records remain widespread, electronic patient records have long been a key feature of UK general practice. By 1996, 96% of general practices were computerised and now almost every primary care consultation in the UK is recorded on a computerised clinical system. Consequently, we now have a vast repository of patient health data that spans decades, which could be used to address a range of important research questions. Unfortunately, accessing primary care data for health researchers can be a burdensome, confusing and time-consuming process. Understanding the way in which primary care data are recorded and 'coded' is not intuitive to those unfamiliar with general practice. The requirements of information governance mean that some data, or data presented in particular ways, are not available at all. This review provides a practical overview of the types of data recorded in primary care, the bodies responsible for them and how they can be accessed.
与手写记录仍广泛存在的二级医疗不同，电子病历长期以来一直是英国全科医疗的一个关键特征。到1996年，96%的全科医疗实现了计算机化，如今英国几乎每一次基层医疗会诊都记录在计算机化临床系统中。因此，我们现在拥有一个跨越数十年的庞大患者健康数据存储库，可用于解决一系列重要的研究问题。不幸的是，对于健康研究人员来说，获取基层医疗数据可能是一个繁重、令人困惑且耗时的过程。对于不熟悉全科医疗的人来说，理解基层医疗数据的记录和“编码”方式并非易事。信息治理的要求意味着某些数据或以特定方式呈现的数据根本无法获取。本综述提供了基层医疗中记录的数据类型、负责这些数据的机构以及如何获取这些数据的实用概述。
