Where is the relevant history and examination recorded? A review of documents in general practice

Jiwa, Moyez MA MD FRACGP MRCGP
Gordon, Michael MBBS BMedSci
Skinner, Paul FRCS
Colwell, Bridgitte
Freeman, Jennifer PhD

Professor of Primary Care, Curtin University of Technology, Perth, Australia
General Practitioner, Gleadless Medical Centre, Sheffield, UK
Colorectal Surgeon, Northern General Hospital, Sheffield, UK
Project Manager, Institute of General Practice and Primary Care (ScHARR), University of Sheffield, UK
Lecturer in Medical Statistics, University of Sheffield, UK

FUNDING BODY

Funded by the Sheffield Health and Social Research Consortium.

ETHICS COMMITTEE

Reviewed by the North Sheffield Research Ethics Committee (NS 2004 2 1861).

CONFLICTS OF INTEREST

None.

ADDRESS FOR CORRESPONDENCE

Moyez Jiwa, Professor of Primary Care, WA Centre for Cancer and Palliative Care, Health Research Campus, Box U1987, Perth, WA 6845, Australia. Tel: +61 8 9266 1768; fax: +61 8 9266 1770; email: [email protected]

Received 18 September 2006

Accepted 20 October 2006

Quality in Primary Care 14(4):p 235-238, 2006.

This study aimed to compare specific clinical parameters as recorded in a matched set of general practice medical records and referral letters relating to patients with lower bowel symptoms referred to a colorectal surgeon in the UK. Data from 48 matched documents suggest that there is more relevant information recorded in referral letters than in the general practice records. There was an absence of important details recorded in either document.