Record Keeping in Norwegian General Practice

Abstract

Routines of medical record keeping were studied in a random sample of 50 out of 228 general practitioners in two counties, Möre & Romsdal and Sör-Tröndelag. One doctor refused to participate and one had retired. The 48 physicians were interviewed and a questionnaire was completed with details about their record keeping. The standard of the records was assessed according to legibility, quality of notes, past history and tidiness using a score system.

All general practitioners had records for every patient, but the quality of the records varied considerably. More than 50 per cent used handwriting in progress notes, which varied from diagnostic labels to extended reports. Few records contained accessible background information about the patient concerned, and many records contained large amounts of old and irrelevant papers. The record-scores varied from 3 to maximum 10 with an average of 6.7.

Higher Standards of recording in general practice are called for, since the quality of records does not only affect the individual patient, but, in the end, the quality of medical care in general.

Key Words:

• Medical records
• Record Keeping
• General practice
• Family practice
• Assessment