An automated records system for general practice.

Abstract

The general practitioner through his contract with the local Executive Council is responsible for the medical care of a named group of people. Additionally he may from time to time accept responsibility for temporary residents. The average general practitioner has 2,500 to 3,000 patients on his list, and any one of these may consult him at any time. Thus in any general practitioner records system it is necessary to maintain an 'active file' of records available at short notice for all persons registered. This presents a different problem from that of a hospital where most transactions are covered by a relatively small file with very high activity and a large file from which records may be retrieved over a period of hours or days, rather than seconds or minutes. During the course of one year between 8 and 12% of patients registered with the general prac titioner would be expected to leave his list and a similar number will register. Additionally some people who remain registered with the general practitioner will change their addresses, or their names on marriage, so that it is necessary to make these and other amendments to the basic patient record. This paper describes the methodology of setting up a computer-based practice file and of its con tinuous updating. This is the first phase of a feasi bility study to establish an automated computer based records system for administrative and research purposes. Some of the potential rewards of the system are discussed later. No attempt is being made to include records for clinical management in this system, since, as Marinker (1969) has pointed out, the unstructured nature of clinical notes presents the greatest obstacle to the application of electronic methods to data collection.