The medico-professional quality of GP consultations assessed by analysing patient records

作者：Kuusela Maisa^*; Koivisto Anna Liisa; Vainiomaki Paula; Vahlberg Tero; Rautava Paivi

来源：Scandinavian Journal of Primary Health Care, 2011, 29(4): 222-226.

DOI：10.3109/02813432.2011.628241

• Acute respiratory infections
• consultation
• electronic patient records
• general practice
• hypertension
• quality of health care

Objective. To assess the medico-professional quality of consultations by analysing textual data from patient records. Design. Qualitative analyse of textual data. Setting. Four primary health care centres using electronic patient records (EPR) in Finland. Subjects. EPR and paired questionnaires of 175 consultations filled in by GPs and their patients independently. Main outcome measures. Medico-professional quality of consultations, quality of care of acute respiratory infections, and hypertension. Results. The medico-professional quality of the consultations was quite good. However, 9% of the records could not been assessed at all because of missing or poor documentation and 9% were assessed as poor. The treatment of acute respiratory infections and hypertension is not in line with current care guidelines. Smoking habits or other health behaviour or lifestyle factors were seldom recorded. Conclusions. The medico-professional quality of the consultation was quite good. Quality improvement is needed in the treatment of acute respiratory infections and hypertension. User-friendly EPR systems would improve the content of patient records.

• 出版日期2011-12