Doctors, computers and quality of registration. An audit on prescription items and x-ray requests

Abstract

Objective: Medical records are and will be more or less computerised in the nearest future. All health care records need regular standard quality checks. A standard for the quality of health care records is a requirement for research and health care planning needs. It is therefore of interest to know how accurate doctors are in recording information in computer-based record systems.

Methods: Four community health centres with problem-oriented computerised medical record systems participated in this audit. Prescriptions from all the 23 GPs in the participating health centres were retrieved from the local pharmacy and x-ray requests from the local radiology clinic. The medical records of each participating health centre were then searched for these prescriptions and x-rays requests.

Results: A total of 2,011 entries were searched, 1,094 office prescription items, 370 over the phone prescription items, and 547 x-ray requests. Of the office prescription items 163 or 14.8%, of the phone prescription items 80 or 21.0%, and of the x-ray requests 94 or 17.2% were lacking. Variation among the doctors was considerable. GPs entering data themselves and making use of the options on the computer programme had the highest rate of items found.

Conclusion: Data entered directly into a computer is more fully recorded than data first written on paper and transferred later into a computer. Well motivated GPs using computer programmes are a valuable source for research and health care planning. The results of this audit are of importance in the continuing development of computer-based record systems, and increase our understanding of how doctors use and respond to computers.