Table 2.
Indicators of quality in the medical record for 249 consultations from 25 general practitioners using paperless records and for 280 consultations from 28 general practitioners using paper based records. Values are numbers (percentages) unless stated otherwise
| Paperless records (n=249) | Paper based records (n=280) | P value of difference* | |
|---|---|---|---|
| Is there an entry? | |||
| No
|
1 (0.4)
|
4 (1.4)
|
0.25
|
| Yes
|
248 (99.6)
|
276 (98.6)
|
|
| Is entry legible? | |||
| No
|
0
|
16 (5.7)
|
|
| Partially
|
0
|
84 (30.0)
|
<0.0001 |
| Yes | 249 (100) | 180 (64.3) | |
| Is entry understandable? | |||
| No
|
2 (0.8)
|
19 (6.8)
|
|
| Partially | 24 (9.6) | 62 (22.1) | 0.0001 |
| Yes
|
222 (89.2)
|
193 (68.9)
|
|
| Not applicable | 1 (0.4) | 6 (2.1) | |
| Does entry seem medically appropriate? | |||
| No
|
4 (1.6)
|
10 (3.6)
|
|
| Partially
|
13 (5.2)
|
15 (5.4)
|
|
| Yes
|
224 (90.0)
|
217 (77.5)
|
0.37 |
| Not applicable
|
3 (1.2)
|
18 (6.4)
|
|
| Unsure | 5 (2.0) | 20 (7.1) | |
| Diagnosis recorded | 120 (48.2) | 94 (33.6) | 0.05 |
| Reason for encounter recorded | 239 (96.0) | 264 (94.3) | 0.56 |
| Symptoms | 181 (72.7) | 181 (64.6) | 0.17 |
| Medical history | 18 (7.2) | 13 (4.6) | 0.24 |
| Family history | 11 (4.4) | 5 (1.8) | 0.09 |
| Social history | 22 (8.8) | 34 (12.1) | 0.30 |
| Lifestyle | 13 (5.2) | 24 (8.6) | 0.20 |
| Patient views | 29 (11.6) | 26 (9.3) | 0.45 |
| Physical examination recorded | 130 (52.2) | 125 (44.6) | 0.21 |
| Clinical values | 42 (16.9) | 61 (21.8) | 0.30 |
| Certification | 18 (7.2) | 16 (5.7) | 0.51 |
| Investigations recorded in notes | 41 (16.5) | 41 (14.6) | 0.62 |
| Referrals made: | 31 (12.4) | 37 (13.2) | 0.80 |
| Specialty recorded | 24/31 (77) | 22/37 (59) | 0.03 |
| Advice given | 59 (23.7) | 30 (10.7) | 0.017 |
| Prescription issued: | 127 (51.0) | 133 (47.5) | 0.52 |
| Dose recorded | 110/127 (87) | 88/133 (66) | 0.005 |
| Frequency recorded | 65/127 (51) | 77/133 (58) | 0.55 |
*
With clustering by general practitioner taken into account.