The electronic patient record in primary care—regression or progression? A cross sectional study

Appendix: Definitions used in assessing medical records:

Numbers of words, numbers, abbreviations, symbols, and drawings:

A word is any whole (not abbreviated) word. All words on the consultation record should be counted. Do not include name of surgery. The name of the GP or his or her initials should be counted in the initials field. If no words appear enter 0.

A number would have come from taking the history—for example, the number of episodes or the duration of an illness in days, the number of tablets, or numbers of siblings. It does not include blood pressure readings or body mass index readings—these are values. If no numbers are recorded enter 0.

An abbreviation is any abbreviation of a whole word used—for example, ct, ref, Ix, &, £, L (also when in a circle), R (also when in a circle), c. See attached sheets for full list of abbreviations. If no abbreviations are recorded enter 0.

A symbol is used to represent a word. The following represents all the symbols to be included ü , ?, ??, +, ++, +++, ++++, %, ° , ­λ , ® , ¯ , # , ∗ , =, +/-, x, < , Δ , ¿ . If no symbols are recorded enter 0.

A drawing is any illustrative representation in the notes. It is cruder than a symbol and is open to interpretation. If no drawings are recorded enter 0. Examples of a drawing:

If there is an entry, for example,   the circle is to count as a drawing and 60 as a single value.

Other definitions

For previous medical history include any mention of a condition that the patient has had previously or still has but is not the reason for encounter—for example, previous MI. Include only explicit recording rather than inference. It means any positive or negative previous events.

For symptoms include any symptoms described in the record—for example, "He came with a cough and complaining of breathlessness."

For social history include, for example, discussions about housing, employment, money, marital issues, family, etc.

For advice given include any comments indicating that the doctor offered the patient general advice—for example, "I told him to take it easy for a while" or "I told her not to do any sport for a month" or "I gave some advice on his inhalers."

For patient views include all references to a patient’s views—for example, evidence of what patient wants or expects from the consultation: "The patient came in wanting some reassurance," "She thought she should be put on the waiting list."

For lifestyle information include references to smoking, alcohol consumption, exercise.